Abstract
PurposeTo describe and evaluate our initial 5-year experience with a new complication registration system for errors in radiology. Materials and methodsThis study reviewed all cases that were submitted to a new complication registration system of a tertiary care radiology department between 2015–2019. ResultsSixty-seven cases were included. In the group of diagnostic complications/errors (n = 34), there were 21 perceptual errors and 13 cognitive errors. This 61.8 % (21/34) perceptual error rate was not significantly different (P = 0.297) from the 70 % perceptual error rate known from previous literature. In the group of interventional complications (n=19), most cases (47.4 % [9/19]) concerned symptomatic or major hemorrhage. In the group of organizational complications/errors (n=14), the leading incident type according to the International Classification System for Patient Safety was clinical process/procedure with wrong body part/side/site as subclassification (35.7 % [5/14]). Harm severities were none (n=35), mild (n=10), moderate (n=10), severe (n=6), death (n=5), and unknown (n=1). Harm severity of interventional complications was significantly higher (P < 0.05) than that of organizational complications, while there were no significant differences in harm severities between other groups of complications. ConclusionIt is feasible to implement the radiologic complication registration system that was described in this study. Perceptual mistakes, hemorrhage, and procedures on the wrong body part/side/site dominated in the categories of diagnostic, interventional, and organizational complications/errors, respectively, and these should be the topic of vigilance in clinical practice and further research. Future studies are also required to determine whether this complication registration system reduces radiologic errors and improves healthcare quality.
Highlights
Hospital systems operate in complex and high-risk environments, in which the risk of error is high [1]
Of these 74 cases, 3 were excluded because they were too poorly reported to understand the nature of the complication, and 4 were excluded because they were not related to any procedure that was performed at the department of radiology
This study described the concept of a new complication registration system for errors in radiology, and its yield in a tertiary care radiology department in a consecutive 5-year period
Summary
Hospital systems operate in complex and high-risk environments, in which the risk of error is high [1]. Errors have been reported to cause an estimated 251,454 deaths in hospitals in the United States each year, and to rank third after cancer and heart disease as the leading cause of death [2]. Error has been recognized as a frequent occurrence in diagnostic radiology for many decades [1]. The retrospective error rate among radiologic examinations has been reported to be approximately 30 %, with real-time errors in daily radiology practice averaging 3–5 % [3,4]. While the diagnostic error rate for radiologists is lower than that of other specialties [5,6], the frequency of errors in interventional radiology has been shown to be comparable to that in the surgical disciplines [7]. The goal is not to eliminate human error but to develop strategies to prevent, identify, and mitigate errors and their effects before they result in harm [1]
Sign-in/Register to view highlights & summary Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
