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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 events. Wrong radiology events reported from July 2016 through June 2017 identified 993 wrong radiology events, including near misses. The events occurred across the imaging process, from the initial step of ordering through performing the study to the final step of communicating results. Errors involved system failures related to identifying patients and ordering and verifying procedures, including study type, body site, and laterality. More than half of the wrong radiology errors were reports of wrong-patient and wrong-side events. The most common wrong imaging events involved radiography studies (44.5%) and CT scans (24.5%). Of the 993 wrong-site radiology events, 646 (65.1%) reached the patient. Contributing factors cited in event-report details included increased workload, miscommunication, complexities related to healthcare technologies, and studies performed outside of radiology departments. Developing and implementing verification processes specific to the medical-imaging care continuum is essential to reduce the risk of harm from wrong radiology events. The alert provides several risk reduction strategies.

Additional Details

Device:
lead x-ray markers, chest tube, central line, endotracheal tube, MRI, CT, PET, portable x-ray
Medication/Gas/Fluid:
contrast media, IV fluids, isotonic crystalloid fluids (e.g. normal saline), metformin
Medication/IV List:
radiocontrast agents, IV, hypoglycemics, oral

Rules / Policies / Procedures
  1. "Applying the Universal Protocol to Improve Patient Safety in Radiology Services," suggested implementing safety processes and checklists for radiology imaging that include elements of verification similar to those in the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™.
  2. Implementing a brief two-person verification approach significantly decreased wrong-patient and wrong-study radiology events.
  3. Implement 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.
  4. Develop 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.
  5. Strategies to decrease the risk for wrong radiology events should include developing verification processes specific to the radiology services environment, resources, and medical-imaging care continuum.
  6. 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.
  7. 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.
  8. 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