Minimizing Digital Imaging and Communications in Medicine (DICOM) Modality Worklist patient/study selection errors.

Frequently when patient and study identification information (patient name, patient identification, date of birth, sex, and accession number) are manually entered at a modality, typographical errors occur that have to be corrected before the acquired images can be matched to the proper patient and study on a picture archiving and communication system (PACS). The Digital Imaging and Communication in Medicine (DICOM) Modality Worklist service alleviates these problems by automatically transferring this data from the radiology information system (RIS) to the image acquisition modality. The technologist then does not have to manually re-enter the data to place it into the image files. With modality worklist, precise patient and study data are obtained and placed into the image headers with no typographical errors. When the images are sent to the PACS, they match the corresponding patient and study records, and are immediately incorporated into the electronic patient record. While modality worklist does replace the manual keying of the data and virtually eliminates typographical problems, it introduces a new source of human error: the incorrect selection of the patient and/or study from the computerized worklist, and the resultant mislabeling of the images. When these mislabeled images are sent to the PACS, they are immediately associated with the wrong patient and/or study, where they potentially may cause serious harm. The goal of this report is to raise awareness to this problem, to identify the major causes of these errors, and to offer some practical suggestions on how to minimize them.