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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 9/1/2018 12:00:00 AM
This alert discusses the patient safety incidents which can occur with wrong radiology processes. The Pennsylvania Department of Health reported that more than 16 million radiology studies were performed by Pennsylvania hospitals in 2016. This high frequency of studies and the complexities of the medical-imaging care continuum put patients at risk for wrong patient, wrong procedure, wrong site, wrong side events. The Pennsylvania Patient Safety Authority analyzed wrong radiology events reported from July 2016 through June 2017. Analysts identified 993 wrong radiology events, including near misses (i.e., events that did not reach the patient). More than half of the wrong radiology errors (51.2%) were reports of wrong-patient and wrong-side events. Of the wrong-site radiology events, (65.1%) reached the patient. The most common wrong imaging events involved radiography studies (44.5%) and CT scans (24.5%). The events occurred across the imaging process, from the initial step of ordering through performing the study to the final step of communicating results. Over half of the events occurred during the procedure stage, and the three most common events types occurring during the procedure stage were wrong patient, 30.5%, wrong side, 23.5%, and wrong site, 21.9%. Errors involved system failures related to identifying patients and ordering and verifying procedures, including study type, body site, and laterality. Contributing factors cited in event-report details included increased workload, miscommunication, complexities related to healthcare technologies, and studies performed outside of radiology departments. Wrong radiology studies can expose patients to risks of harm, from unnecessary radiation exposure or contrast doses to delays in diagnosis or treatment. Developing and implementing verification processes specific to the medical-imaging care continuum is essential to reduce the risk of harm from wrong radiology events. A link to Authority resources for radiology imaging verification, an example of the Generations and Northern Manhattan Network's "Radiology Exam Verification and Time Out" form, and other guidance materials are provided in Supplemental Material in the alert.

Additional Details

Device:
MRI, CT, PET, X-Ray, chest tube, central IV line, endotracheal tube
Medication/Gas/Fluid:
contrast media, metformin, isotonic crystalline fluids, normal saline
Medication/IV List:
hypoglycemics, oral, radiocontrast agents, IV

Rules / Policies / Procedures
  1. A review of the literature found articles describing use of verification processes and checklists for imaging studies that are similar to those used in surgery. For example, Rubio and Hogan found that implementing a brief two-person verification approach significantly decreased wrong-patient and wrong-study radiology events. A presentation at the Radiological Society of North America 2015 annual meeting reported that a hospital in the Generations and Northern Manhattan Network of Bronx, New York, implemented a "Radiology Exam Verification and Time Out" process. This time-out by the radiology technologist and another healthcare provider occurs at the location of the study (e.g., radiology area, neonatal unit, emergency department) and includes a two-person verification of patient identifiers, procedure to be performed, site, laterality, site marking, contrast (orders and expiration date if applicable) and pregnancy screening. Both the technologist and witness initial each item of verification then sign an acknowledgement that all the steps of verification were completed.
  2. Einstein Healthcare Network of Philadelphia, Pennsylvania, has developed a clinical decision support process for ordering CT scans. The tiered approach uses two different platforms, an evidenced-based algorithm embedded in the electronic medical record (EMR) to help clinicians decide whether a CT scan is indicated and a clinical decision support imaging tool which advises whether or not an ordered scan is appropriate. The utilization of these platforms standardizes advanced radiologic procedure clinician ordering, with the intent to decrease exposure to unnecessary radiation and improve workflow, which could significantly decrease wrong-procedure errors.
  3. Creating a culture of safety, which encourages reporting and sharing of radiology safety events by staff (including near miss events), provides opportunities to learn about and reduce risk of harm to patients.
  4. Analysis by radiology staff of wrong radiology events and where they occur along the facility's medical-imaging care continuum can identify areas of vulnerability and points along the continuum where implementing a verification process might decrease the risk of wrong radiology events.
  5. Verification processes should include confirmation that all sources of information relevant to the planned imaging agree, including the written order or prescription, the electronic order, the documentation or electronic record, and the patient or parent report. Every detail (patient identifiers; procedure to be completed, including laterality and site; reason for the procedure) from each source should agree. Any discrepancies should be resolved before the procedure is initiated.

Adapting Verification Processes to Prevent Wrong Radiology Events