RSNA 2014 

Abstract Archives of the RSNA, 2014


HPS162

Incidence and Etiology of Ionizing Radiation Misadministrations at a Tertiary Care Academic Medical Center: A Retrospective Five Year Review

Scientific Posters

Presented on December 3, 2014
Presented as part of HPS-WEA: Health Services Wednesday Poster Discussions

Participants

Amichai Joshua Erdfarb MD, Presenter: Nothing to Disclose
Richard Zampolin MD, Abstract Co-Author: Nothing to Disclose
Judah Burns MD, Abstract Co-Author: Nothing to Disclose
E. Stephen Amis MD, Abstract Co-Author: Nothing to Disclose

PURPOSE

Considerable attention has been given to the issue of misadministrations in diagnostic imaging, however no benchmarks for monitoring such events are routinely used. Although patient identification errors have been demonstrated to contribute to such events, there is a paucity of information regarding other error sources. The purpose of this study is to determine the incidence and etiology of ionizing radiation misadministrations at a tertiary-care academic medical center in order to develop benchmarks for comparison and to identify specific factors that contribute to such events in an effort to develop appropriate remediations.

METHOD AND MATERIALS

All misadministrations of ionizing radiation from 2008-2012 were reviewed and categorized by event type (repeat examination, patient, procedure, site, and laterality errors), by whether the exam was performed in the Department of Radiology or on an inpatient unit, and by the proximate cause, for example, patient misidentification or incorrect order placement.

RESULTS

From 2008-2012 1,819,445 exams were performed with 141 associated misadministrations, resulting in an incidence of 1:12904. Plain radiographs accounted for 70% (1:13544) of these, and CT imaging for 30% (1:11342). Patient misidentification and exam verification errors resulted in 120 (85%) of the events, however multiple less common errors, including registration errors, order errors by the referring clinician, and wristband errors, were identified and associated with certain event types. For example, of the 19 repeat exams, 8 (42%) resulted from referrer error. Additionally, certain situations seemed to predispose to error. For example, portable exams accounted for 35 (56%) of the wrong-patient events.

CONCLUSION

Multiple factors contribute to misadministrations, underscoring the need to address multiple etiologies when designing a robust quality assurance program designed to eliminate such events. Some of these errors originate outside the Department of Radiology, at the point of referral, requiring the engagement of our clinical colleagues to correct. Similarly, certain external factors, such as the location of the exam, increase the likelihood of an error occurring, highlighting the need to improve site-specific procedures in such settings.

CLINICAL RELEVANCE/APPLICATION

Multiple factors must be addressed when developing a robust quality assurance program designed to eliminate misadministrations of ionizing radiation.

Cite This Abstract

Erdfarb, A, Zampolin, R, Burns, J, Amis, E, Incidence and Etiology of Ionizing Radiation Misadministrations at a Tertiary Care Academic Medical Center: A Retrospective Five Year Review.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14006250.html