Bettina Siewert MD, Presenter: Nothing to Disclose

Olga Rachel Brook MD, Abstract Co-Author: Research Grant, Guerbet SA

Jonathan B. Kruskal MD, PhD, Abstract Co-Author: Author, UpToDate, Inc

The purpose of this study is to analyze radiology quality improvement issues that were brought to our attention through hospital personnel working outside of radiology to identify opportunities for improvement and provide better customer service

We collected quality improvement entries and inquiries that were brought to our attention over an eight months period from August 2012 to March 2013. The origin of the complaint reported  to us by personnel working outside of radiology was noted as: electronic hospital patient safety and adverse event reporting system, office for Health Care Quality, office for Patient Relations and hospital e-mail. The radiology component of the cases was categorized into interpretative error, technical error, procedure complication and communication issues. All cases were reviewed and opportunities for improvement were identified.

32 cases were referred to us through: electronic patient safety and adverse event reporting system (n=18), office for Health Care Quality (n=5),  hospital e-mail (n=5), office for Patient Relations (n=4). Errors were classified as communication (n=16) (50%), misread (n=7) (22%),  technical (n=5) (16%), procedure complication (n=4) (12%). Upon review of the cases no opportunities for improvement could be identified in 9 cases (28%) as they represented known procedural complications that could not have been avoided (n=4), perceived "technical errors" where the study had been performed correctly (n=4) (shoulder injury not attributable to mammogram, MRI of the pituitary gland did not identify septic emboli as area of brain was not imaged due to limited field of view, premedication for iv contrast due to shellfsh allergy was not initiated by radiologist, US demonstrated no flow in transplant kidney), communication error (n=1) (radiology resident correctly documented and discussed diagnosis over the phone, but referring physician did not receive information). Four communication errors were due to misconceptions by referring physicians as to radiology department policies.

50% of radiology quality improvement issues reported by personnel working outside of radiology are due to communication issues alone, only 22% are due to an error in image interpretation. In 28% of cases, no opportunity of improvement could be identified.

50% of radiology QA entries though hospital systems are due to perceived lack of communication.

Siewert, B, Brook, O, Kruskal, J, The Big Picture: Radiology Quality Improvement in the Hospital QA Setting: Communication Is (almost) Everything.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13014206.html