Where failures occur in the imaging care cycle lessons from the radiology events register

David Jones, M Thomas, Catherine Mandel, J Grimm, N Hannaford, Timothy Schultz, W Runciman

    Research output: Contribution to journalArticle

    21 Citations (Scopus)

    Abstract

    Adverse events contribute to significant patient morbidity and mortality on a global scale, and this has been documented in a number of international studies. Despite this, there is limited understanding of medical imaging's involvement in such events. Incident reporting is a key feature of high-reliability organizations because, understandably, it is essential to know where things go wrong and why as the very first step in formulating preventative and corrective strategies. Although anesthesiology has led the way, health care in general has been slow to adopt this technique, and this includes medical imaging. Knowledge as to where medical imaging incidents are initiated and detected, and why, is not well documented or appreciated, although this is critical information in relation to quality improvement. Using an online radiology reporting system, the authors therefore sought to gain further insight and also ascertain where failures are located in the imaging cycle, and whether different incidents sources provide different information. Last, the authors sought to examine the resilience of the imaging system using these incident data.

    Original languageEnglish
    Pages (from-to)593-602
    Number of pages10
    JournalJACR-Journal of the American College of Radiology
    Volume7
    Issue number8
    DOIs
    Publication statusPublished - 2010

    Keywords

    • error
    • imaging cycle
    • incident reporting
    • patient safety
    • Radiology

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