Procedure, Communication Errors at Heart of Imaging Safety Events: AHRQ Study

A new AHRQ-funded study of more than 11,500 safety reports found that 7 percent were related to diagnostic imaging. The study, published in the Journal of the American College of Radiology, found that more than half of the imaging-related safety reports, submitted in 2015 from a single medical center, came from the imaging procedure itself, but errors involving communication of results were more serious. Access the abstract. AHRQ is the lead federal agency investing in improving diagnostic safety. Access AHRQ’s diagnostic safety pageto learn about the agency’s diagnostic safety summit, its tools and resources, and funding support for research.

2018 Dec 4. pii: S1546-1440(18)31336-X. doi: 10.1016/j.jacr.2018.10.015. [Epub ahead of print]

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

Lacson R1, Cochon L2, Ip I3, Desai S4, Kachalia A4, Dennerlein J5, Benneyan J6, Khorasani R3.

Author information

Abstract

PURPOSE:

The aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors.

METHODS:

The authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as "potential harm." Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause "potential harm" was compared for each step and sociotechnical factor using χ2 analysis.

RESULTS:

Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P < .0001). The κ coefficient was 0.79.

CONCLUSIONS:

Safety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.