Radiology Research in Quality and Safety

Zygmont, Matthew E.; Itri, Jason N.; Rosenkrantz, Andrew B.; Duong, Phuong-Anh T.; Gettle, Lori Mankowski; Mendiratta‐Lala, Mishal; Scali, Elena P.; Winokur, Ronald S.; Probyn, Linda; Kung, Justin W.; Bakow, Eric; Kadom, Nadja

doi:10.1016/j.acra.2016.07.021

Cited by 16 publications

(12 citation statements)

References 67 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Transitioning away from traditional peer review processes such as RADPEER to alternatives that emphasize peer feedback, learning, and improvement has been advocated (34). A culture that supports learning from diagnostic error must also be a "just culture," which balances the focus on systemslevel issues with individual accountability (54).…”

Section: Culturementioning

confidence: 99%

“…The skills and tools learned can be broadly applied to identification and analysis of diagnostic errors, as well as development and implementation of interventions. There are workshops specific to radiologists and online resources described elsewhere (54). There are also numerous articles in the radiology literature reviewing various aspects of the process, most notably in the Practice Policy and Quality Initiatives section of RadioGraphics and the Quality Matters section of the Journal of the American College of Radiology.…”

Section: Trainingmentioning

confidence: 99%

See 1 more Smart Citation

Fundamentals of Diagnostic Error in Imaging

et al. 2018

Self Cite

View full text Add to dashboard Cite

Imaging plays a pivotal role in the diagnostic process for many patients. With estimates of average diagnostic error rates ranging from 3% to 5%, there are approximately 40 million diagnostic errors involving imaging annually worldwide. The potential to improve diagnostic performance and reduce patient harm by identifying and learning from these errors is substantial. Yet these relatively high diagnostic error rates have persisted in our field despite decades of research and interventions. It may often seem as if diagnostic errors in radiology occur in a haphazard fashion. However, diagnostic problem solving in radiology is not a mysterious black box, and diagnostic errors are not random occurrences. Rather, diagnostic errors are predictable events with readily identifiable contributing factors, many of which are driven by how we think or related to the external environment. These contributing factors lead to both perceptual and interpretive errors. Identifying contributing factors is one of the keys to developing interventions that reduce or mitigate diagnostic errors. Developing a comprehensive process to identify diagnostic errors, analyze them to discover contributing factors and biases, and develop interventions based on the contributing factors is fundamental to learning from diagnostic error. Coupled with effective peer learning practices, supportive leadership, and a culture of quality, this process can unquestionably result in fewer diagnostic errors, improved patient outcomes, and increased satisfaction for all stakeholders. This article provides the foundational elements for implementing this type of process at a radiology practice, with examples to help radiologists and practice leaders achieve meaningful practice improvement. ©

show abstract

Section: Culturementioning

confidence: 99%

Section: Trainingmentioning

confidence: 99%

Fundamentals of Diagnostic Error in Imaging

et al. 2018

Self Cite

View full text Add to dashboard Cite

show abstract

“…Incident reporting systems can improve system safety in high-risk and high-reliability organizations (4). In the United States, adoption of incident reporting systems has been reported to be generally slow, poorly coordinated, and to lack systemic and multidisciplinary analysis of incidents (4,5). On the other hand, in the Netherlands, the use of incident reporting systems has been compulsory by law since 2008 Our tertiary care center employs an incident reporting system specifically for radiology-related matters.…”

Section: Introductionmentioning

confidence: 99%

Patient safety incidents in radiology: frequency and distribution of incident types

et al. 2020

View full text Add to dashboard Cite

Background Patient safety incidents may be a valuable source of information to learn from and to prevent future errors. Purpose To determine the distribution of patient safety incident types in radiology according to the International Classification for Patient Safety (ICPS), and to comprehensively review those incidents that were either harmful or serious in terms of risk of patient harm and reoccurrence. Material and Methods The most recent five-year database (2014–2019) of a radiology incident reporting system was evaluated. Results A total of 480 patient safety incidents were included. Top three ICPS incident types were clinical administration (119/480, 24.8%), resources/organizational management (112/480, 23.3%), and clinical process/procedure (91/480, 19.0%). Harm severities were none in 457 (95.2%) cases, mild in 14 (2.9%), moderate in 4 (0.8%), severe in 3 (0.6%), and unknown in one case. Subsequent Prevention Recovery Information System for Monitoring and Analysis (PRISMA) reviews were performed in 4 (0.8%) cases. The three patient safety incidents that caused severe harm (of which one underwent PRISMA review) involved resources/organizational management (n = 1), clinical process/procedure (n = 1), and medication/IV fluids (n = 1). Three other cases (with no harm in two cases and moderate harm in one case) that underwent PRISMA review involved resources/organizational management (n = 2) and medical device/equipment/property (n = 1). Conclusion Radiology-related patient safety incidents predominantly occur in three ICPS domains (clinical administration, resources/organizational management, and clinical process/procedure). Harmful/serious incidents are relatively rare. The standardly and transparently reported findings from this study may be used for healthcare quality improvement, benchmarking purposes, and as a primer for future studies.

show abstract

“…The IOM recommends a strategy to reduce adverse events by providing leadership, promoting effective team functioning, creating a learning environment and implementing nonpunitive systems for reporting and analyses. 11 To date, Zygmont et al (2017) have developed these guidelines to focus on educational curricula, effective data infrastructures, designed reporting systems, and validated performance measures. 12 In Finland, when an incident concerns radiation safety, it is reported to the Radiation and Nuclear Safety Authority (STUK).…”

Section: Introductionmentioning

confidence: 99%

“…11 To date, Zygmont et al (2017) have developed these guidelines to focus on educational curricula, effective data infrastructures, designed reporting systems, and validated performance measures. 12 In Finland, when an incident concerns radiation safety, it is reported to the Radiation and Nuclear Safety Authority (STUK). According to Finland's Radiation Act (859/2018) any abnormal event pertaining to the use of radiation that is substantially detrimental to the radiation safety of workers, patients or the environment must be reported.…”

Section: Introductionmentioning

confidence: 99%

Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

et al. 2020

View full text Add to dashboard Cite

Adverse events in radiology are quite rare, but they do occur. Radiation safety regulations and the law obligate organizations to report certain adverse events, harm and near misses, especially events related to patients' health and safety. The aim of this study was to describe and analyse incidents related to radiation safety issues reported in Finland. MethodsThe data were collected from incident reports documented by radiology personnel concerning notifications of abnormal events in medical imaging made to the Radiation and Nuclear Safety Authority between 2010 and 2017. During these eight years, 312 reports were submitted. Only events reported from radiology departments were included; nuclear medicine, radiotherapy and animal radiology cases were excluded. The final number of reports was 293 (94%). ResultsThe majority of the 293 approved reports were related to computed tomography (CT, 68.3%) and to X-ray examinations (27.6%). Altogether 82.9% of those irradiated were adults, most of whom were exposed to unnecessary radiation through CT (86.5%), 5.5% were children, and 4.4% pregnant women. The most common effective dose of unnecessary radiation was 1 mSv or less (89.7% of all examinations). The highest effective doses were reported in CT (from under 1 mSv-20 mSv and above). The reasons for the adverse events were incorrect identification (32%), incorrect procedure, site or side (30%); and human errors or errors of knowledge Data selection (20%). ConclusionAdverse events occurred especially in CT examinations. It is important to collect and analyse incident data, assess the harmful events, learn from them and aim to reduce adverse events.

show abstract

Radiology Research in Quality and Safety

Cited by 16 publications

References 67 publications

Fundamentals of Diagnostic Error in Imaging

Fundamentals of Diagnostic Error in Imaging

Patient safety incidents in radiology: frequency and distribution of incident types

Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland

Contact Info

Product

Resources

About