Literature DB >> 26246282

Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports.

Mohammad Mansouri1, Khalid W Shaqdan2, Shima Aran3, Ali S Raja4, Michael H Lev5, Hani H Abujudeh6.   

Abstract

The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.

Entities:  

Keywords:  Emergency radiology; Incident report; Incident reporting system; Quality and safety; Quality improvement; Safety incident reporting system

Mesh:

Year:  2015        PMID: 26246282     DOI: 10.1007/s10140-015-1336-3

Source DB:  PubMed          Journal:  Emerg Radiol        ISSN: 1070-3004


  16 in total

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2.  Incidence of intravenous contrast extravasation: increased risk for patients with deep brachial catheter placement from the emergency department.

Authors:  Andrew D Hardie; Borko Kereshi
Journal:  Emerg Radiol       Date:  2014-01-07

3.  Patient safety event reporting in a large radiology department.

Authors:  Stacy R Schultz; Robert E Watson; Sherrie L Prescott; Karl N Krecke; Kenneth T Aakre; Mohammad N Islam; Anthony W Stanson
Journal:  AJR Am J Roentgenol       Date:  2011-09       Impact factor: 3.959

4.  Adverse reactions to ionic and nonionic contrast media. A report from the Japanese Committee on the Safety of Contrast Media.

Authors:  H Katayama; K Yamaguchi; T Kozuka; T Takashima; P Seez; K Matsuura
Journal:  Radiology       Date:  1990-06       Impact factor: 11.105

5.  Intravenous contrast extravasation during CT: a national data registry and practice quality improvement initiative.

Authors:  Thomas M Dykes; Mythreyi Bhargavan-Chatfield; Raymond B Dyer
Journal:  J Am Coll Radiol       Date:  2014-09-22       Impact factor: 5.532

6.  Outpatient falls prevention program outcome: an increase, a plateau, and a decrease in incident reports.

Authors:  Hani H Abujudeh; Shima Aran; Laleh Daftari Besheli; Karen Miguel; Elkan Halpern; James H Thrall
Journal:  AJR Am J Roentgenol       Date:  2014-09       Impact factor: 3.959

7.  Clinical observation of the adverse drug reactions caused by non-ionic iodinated contrast media: results from 109,255 cases who underwent enhanced CT examination in Chongqing, China.

Authors:  X Li; J Chen; L Zhang; H Liu; S Wang; X Chen; J Fang; S Wang; W Zhang
Journal:  Br J Radiol       Date:  2015-01-13       Impact factor: 3.039

8.  Characteristics of falls in a large academic radiology department: occurrence, associated factors, outcomes, and quality improvement strategies.

Authors:  Hani Abujudeh; Rathachai Kaewlai; Baiju Shah; James Thrall
Journal:  AJR Am J Roentgenol       Date:  2011-07       Impact factor: 3.959

9.  Frequency and severity of adverse effects of iodinated and gadolinium contrast materials: retrospective review of 456,930 doses.

Authors:  Christopher H Hunt; Robert P Hartman; Gina K Hesley
Journal:  AJR Am J Roentgenol       Date:  2009-10       Impact factor: 3.959

10.  Acute adverse reactions to gadopentetate dimeglumine and gadobenate dimeglumine: experience with 32,659 injections.

Authors:  Hani H Abujudeh; Vijaya K Kosaraju; Rathachai Kaewlai
Journal:  AJR Am J Roentgenol       Date:  2010-02       Impact factor: 3.959

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  5 in total

1.  Highlights from the scientific and educational abstracts presented at the ASER 2015 annual scientific meeting and postgraduate course.

Authors:  Lee A Myers; Keith D Herr
Journal:  Emerg Radiol       Date:  2016-02-16

2.  Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports.

Authors:  Elizabeth J Snyder; Wei Zhang; Kimberly Chua Jasmin; Sam Thankachan; Lane F Donnelly
Journal:  Pediatr Radiol       Date:  2018-08-29

3.  How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center.

Authors:  Mohammad Mansouri; Shima Aran; Khalid W Shaqdan; Hani H Abujudeh
Journal:  Eur Radiol       Date:  2015-11-11       Impact factor: 5.315

4.  Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports.

Authors:  Camilo Jaimes; Diana J Murcia; Karen Miguel; Cathryn DeFuria; Pallavi Sagar; Michael S Gee
Journal:  Pediatr Radiol       Date:  2017-10-19

5.  Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework.

Authors:  Ronilda Lacson; Laila Cochon; Ivan Ip; Sonali Desai; Allen Kachalia; Jack Dennerlein; James Benneyan; Ramin Khorasani
Journal:  J Am Coll Radiol       Date:  2018-12-07       Impact factor: 5.532

  5 in total

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