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.
lead x-ray markers, chest tube, central line, endotracheal tube, MRI, CT, PET, portable x-ray
isotonic crystalloid fluids (e.g. normal saline),
radiocontrast agents, IV,
Adapting Verification Processes to Prevent Wrong Radiology Events