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.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
The Joint Commission. Sentinel Event Policy for Hospitals [Internet]. Available from: https://www.jointcommission.org/assets/1/6/CAMH_SE_0717.pdf. Accessed 2 April 2018
Hannaford N, Mandel C, Crock C et al (2013) Learning from incident reports in the Australian medical imaging setting: handover and communication errors. Br J Radiol 86:20120336
Stewart MJ, Georgiou A, Hordern A et al (2012) What do radiology incident reports reveal about in-hospital communication processes and the use of health information technology? Stud Health Technol Inform 178:213–218
Mansouri M, Shaqdan KW, Aran S et al (2015) Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports. Emerg Radiol 22:623–630
Mansouri M, Aran S, Harvey HB et al (2016) Rates of safety incident reporting in MRI in a large academic medical center. J Magn Reson Imaging 43:998–1007
Mansouri M, Aran S, Shaqdan KW, Abujudeh HH (2016) Rating and classification of incident reporting in radiology in a large academic medical center. Curr Probl Diagn Radiol 45:247–252
Schultz SR, Watson RE Jr, Prescott SL et al (2011) Patient safety event reporting in a large radiology department. AJR Am J Roentgenol 197:684–688
Jaimes C, Murcia DJ, Miguel K et al (2018) Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports. Pediatr Radiol 48:66–73
Steering Committee on Quality Improvement and Management and Committee on Hospital Care (2011) Policy statement -- principles of pediatric patient pafety: reducing harm due to medical care. Pediatrics 127:1199–1210
Donnelly LF, Dorfman SR, Jones J, Bisset GS 3rd (2017) Transition from peer review to peer learning: experience in a radiology department. J Am Coll Radiol 15:1143–1149
Malviya S, Voepel-Lewis T, Eldevik OP et al (2000) Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth 84:743–748
Dalal PG, Murray D, Cox T et al (2006) Sedation and anesthesia protocols used for magnetic resonance imaging studies in infants: provider and pharmacologic considerations. Anesth Analg 103:863–868
Schulte-Uentrop L, Goepfert MS (2010) Anaesthesia or sedation for MRI in children. Curr Opin Anaesthesiol 23:513–517
Kang R, Shin YH, Gil N-S et al (2017) A comparison of the use of propofol alone and propofol with midazolam for pediatric magnetic resonance imaging sedation - a retrospective cohort study. BMC Anesthesiol 17:138
Boriosi JP, Eickhoff JC, Klein KB, Hollman GA (2017) A retrospective comparison of propofol alone to propofol in combination with dexmedetomidine for pediatric 3T MRI sedation. Paediatr Anaesth 27:52–59
Vanderby SA, Babyn PS, Carter MW et al (2010) Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology 256:229–237
Olisemeke B, Chen YF, Hemming K, Girling A (2014) The effectiveness of service delivery initiatives at improving patients’ waiting times in clinical radiology departments: a systematic review. J Digit Imaging 27:751–778
Dako F, Cobb R, Verdi S et al (2018) Use of value stream mapping to reduce outpatient CT scan wait times. J Am Coll Radiol 15:82–85
White BA, Yun BJ, Lev MH, Raja AS (2017) Applying systems engineering reduces radiology transport cycle times in the emergency department. West J Emerg Med 18:410–418
Owens A (2016) Interventional radiology patient throughput QI project. J Radiol Nurs 35:153
Marquez LO, Stewart H (2005) Improving medical imaging report turnaround times: the role of technology. Radiol Manage 27:26–31
Halsted MJ, Froehle CM (2008) Design, implementation, and assessment of a radiology workflow management system. AJR Am J Roentgenol 191:321–327
Starmer AJ, Spector ND, Srivastava R et al (2014) Changes in medical errors after implementation of a handoff program. N Engl J Med 371:1803–1812
Sutcliffe KM, Lewton E, Rosenthal MM (2004) Communication failures: an insidious contributor to medical mishaps. Acad Med 79:186–194
Rees P, Edwards A, Powell C et al (2017) Patient safety incidents involving sick children in primary Care in England and Wales: a mixed methods analysis. PLoS Med 14:e1002217
Siewert B, Brook OR, Hochman M, Eisenberg RL (2016) Impact of communication errors in radiology on patient care, customer satisfaction, and work-flow efficiency. AJR Am J Roentgenol 206:573–579
Jones DN, Thomas MJ, Mandel CJ et al (2010) Where failures occur in the imaging care cycle: lessons from the radiology events register. J Am Coll Radiol 7:593–602
Paquette V, McGloin R, Northway T et al (2011) Describing intravenous extravasation in children (DIVE study). Can J Hosp Pharm 64:340–345
Bellin M-F, Jakobsen JA, Tomassin I et al (2002) Contrast medium extravasation injury: guidelines for prevention and management. Eur Radiol 12:2807–2812
Amaral JG, Traubici J, BenDavid G et al (2006) Safety of power injector use in children as measured by incidence of extravasation. AJR Am J Roentgenol 187:580–583
Gulani V, Calamante F, Shellock FG et al (2017) Gadolinium deposition in the brain: summary of evidence and recommendations. Lancet Neurol 16:564–570
McDonald RJ, McDonald JS, Kallmes DF et al (2015) Intracranial gadolinium deposition after contrast-enhanced MR imaging. Radiology 275:772–782
de Feijter JM, de Grave WS, Muijtjens AM et al (2012) A comprehensive overview of medical error in hospitals using incident-reporting systems, patient complaints and chart review of inpatient deaths. PLoS One 7:e31125
Nuckols TK, Bell DS, Liu H et al (2007) Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care 16:164–168
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflicts of interest
None
Rights and permissions
About this article
Cite this article
Snyder, E.J., Zhang, W., Jasmin, K.C. et al. Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports. Pediatr Radiol 48, 1867–1874 (2018). https://doi.org/10.1007/s00247-018-4238-1
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00247-018-4238-1