Radiology errors: are we learning from our mistakes?

Mankad, Kshitij; Hoey, Edward T.D.; Jones, Jeremy; Tirukonda, Prasanna; Smith, Jonathan

doi:10.1016/j.crad.2009.06.002

Cited by 23 publications

(16 citation statements)

References 16 publications

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“…[18][19][20][21][22][23] This focus on diagnostic errors continued even after the IOM report's mandate to examine systems' contributions to medical errors. [25][26][27][28] The findings of our multicenter collaborative study confirmed earlier investigations that suggest that the most reported subtype of radiologic errors, which in our cohort were over half of the events, are related to misread or changed readings. 18,21,22 Many clinicians would agree that errors and variations in the interpretation of images now represent the most vulnerable area prone to radiologic error.…”

Section: Discussionsupporting

confidence: 92%

Radiologic Safety Events Within a Pediatric Emergency Medicine Network

Blumberg¹,

Mahajan

O’Connell

et al. 2017

Pediatr Emer Care

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We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.

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Section: Discussionsupporting

confidence: 92%

Radiologic Safety Events Within a Pediatric Emergency Medicine Network

Blumberg¹,

Mahajan

O’Connell

et al. 2017

Pediatr Emer Care

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“…Radiological errors were initially studied by Dr. Garland in 1949 establishing the incidence of radiological errors in the range of 15–30% [[1], [2], [3]]. It is important for radiologists to learn from their mistakes to help improve patient care.…”

Section: Introductionmentioning

confidence: 99%

“Learning from my experience”: Acute abdomen - Perforated Meckel's diverticulitis

Brackett

Khullar-Gupta

2019

European Journal of Radiology Open

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Highlights Acute surgical abdomen has a limited differential in pediatric population. Meckel’s diverticulum can mimic the clinical findings of acute appendicitis. Careful radiographic review to identify the appendix in the pediatric population with acute abdomen. Surgical pathology of a normal appendix and a perforated Meckel’s Diverticulitis, with a retrospective view of the appendix.

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“…The next day, the case was found on the picture archiving and communications system, resulting in delayed diagnosis of a cerebral aneurysm. (27) Not performed/no handover provided 11 (20) Inadequate/no post-procedure instructions communicated 8 (15) Clinical history or condition incomplete/inadequate 6 (11)…”

Section: Communication Of Diagnosismentioning

confidence: 99%

“…Review of incident data informs patient safety and can improve the quality of care [19][20][21]. The Radiology Events Register (RaER) commenced in 2006 and it facilitates systematic data collection of incidents and discrepancies in all areas of medical imaging.…”

mentioning

confidence: 99%

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

Hannaford

Mandel²,

Crock³

et al. 2013

BJR

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Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence.Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n5298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging.Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion:The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information

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Radiology errors: are we learning from our mistakes?

Cited by 23 publications

References 16 publications

Radiologic Safety Events Within a Pediatric Emergency Medicine Network

Radiologic Safety Events Within a Pediatric Emergency Medicine Network

“Learning from my experience”: Acute abdomen - Perforated Meckel's diverticulitis

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

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