Elizabeth J Snyder1,2, Wei Zhang1, Kimberly Chua Jasmin1, Sam Thankachan1, Lane F Donnelly3,4,5. 1. Department of Radiology, Texas Children's Hospital, Houston, TX, USA. 2. Department of Radiology, Vanderbilt University, Nashville, TN, USA. 3. Department of Radiology, Texas Children's Hospital, Houston, TX, USA. lane.donnelly@stanford.edu. 4. Center for Pediatric and Maternal Value, Lucile Packard Children's Hospital at Stanford, Stanford Children's Health, 180 El Camino Real, Ste. M384, Mail Code: 5885, Palo Alto, CA, 94304, USA. lane.donnelly@stanford.edu. 5. Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, USA. lane.donnelly@stanford.edu.
Abstract
BACKGROUND: Incident reporting can be used to inform imaging departments about adverse events and near misses. OBJECTIVE: To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports. MATERIALS AND METHODS: All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed. RESULTS: During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001). CONCLUSION: Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.
BACKGROUND: Incident reporting can be used to inform imaging departments about adverse events and near misses. OBJECTIVE: To study incident reports submitted during a 5-year period at a large pediatric imaging system to evaluate which imaging modalities and other factors were associated with a greater rate of filed incident reports. MATERIALS AND METHODS: All incident reports filed between 2013 and 2017 were reviewed and categorized by modality, patient type (inpatient, outpatient or emergency center) and use of sedation/anesthesia. The number of incident reports was compared to the number of imaging studies performed during that time period to calculate an incident report rate for each factor. Statistical analysis of whether there were differences in these rates between factors was performed. RESULTS: During the study period, there were 2,009 incident reports filed and 1,071,809 imaging studies performed for an incident report rate of 0.19%. The differences in rates by modality were statistically significant (P=0.0001). There was a greater rate of incident reports in interventional radiology (1.54%) (P=0.0001) and in magnetic resonance imaging (MRI) (0.62%) (P=0.001) as compared to other imaging modalities. There was a higher incident report rate for inpatients (0.34%) as compared to outpatient (0.1%) or emergency center (0.14%) (P=0.0001). There was a higher rate of incident reports for patients under sedation (1.27%) as compared to non-sedated (0.12%) (P=0.0001). CONCLUSION: Using incident report rates as a proxy for potential patient harm, the areas of our pediatric radiology service that are associated with the greatest potential for issues are interventional radiology, sedated patients, and inpatients. The areas associated with the least risk are ultrasound (US) and radiography. Safety improvement efforts should be focused on the high-risk areas.
Authors: D Neil Jones; M J W Thomas; Catherine J Mandel; J Grimm; N Hannaford; Timothy J Schultz; William Runciman Journal: J Am Coll Radiol Date: 2010-08 Impact factor: 5.532
Authors: Sonya A Vanderby; Paul S Babyn; Michael W Carter; Susan M Jewell; Patricia D McKeever Journal: Radiology Date: 2010-05-26 Impact factor: 11.105
Authors: Marie-France Bellin; Jarl A Jakobsen; Isabelle Tomassin; Henrik S Thomsen; Sameh K Morcos; H S Thomsen; S K Morcos; T Almén; P Aspelin; M F Bellin; W Clauss; H Flaten; N Grenier; J-M Ideé; J A Jakobsen; G P Krestin; F Stacul; J A W Webb Journal: Eur Radiol Date: 2002-09-06 Impact factor: 5.315