Identifying and Classifying Incidents Related to Health Information Technology in Medical Imaging as a Basis for Improvements in Practice

Abstract

The Joint Commission in the United States disseminated a Sentinel Event Alert because of the number of adverse outcomes from problems with health information technology (HIT). The HITs were trading off safety and quality against throughput or efficiency. The Alert urged healthcare providers to improve process measurement and provide leadership in mitigating the risks. In order to understand what problems compromise safety and efficiency, this study has accessed, deconstructed, categorized and analyzed Australian patient safety incident reports of the things that go wrong in medical imaging, and their impact on both patients and the medical imaging acquisition and processing systems. Data Sources comprised two sets of voluntary incident reports and convenience samples of interviews with radiology staff. A special targeted search was undertaken for identifying HIT related incidents so that they could be deconstructed with the health information technology classification system. This resulted in 436 HIT related incidents. Within these incidents, 623 HIT related issues were found. These included use or human factor related issues (40%), software and hardware related issues (30%) and machine related issues (30%). Although many technical problems and deficiencies were detected in the reports identified, we did not anticipate that more than half of the incidents would have involved failures of human performance. Identifying and characterizing the things that are going wrong, related to HIT through the lens of medical imaging incident reports can provide a basis for preventing issues and improving clinical practice.