Resmi Charalel MD, Presenter: Nothing to Disclose

Ian Ross Drexler MD, MBA, Abstract Co-Author: Nothing to Disclose

Pina Christine Sanelli MD, Abstract Co-Author: Nothing to Disclose

Michael Lyon Loftus MD, MBA, Abstract Co-Author: Nothing to Disclose

Keith David Hentel MD, MS, Abstract Co-Author: Nothing to Disclose

Robert J. Min MD, Abstract Co-Author: Medical Advisory Board, Sapheon, Inc

To identify most common types and sources of imaging study near-misadministration in order to develop tailored solutions for prevention and improvement in quality and patient safety.

Detailed analysis of near-misadministration events in imaging studies was performed over a five-month period as part of departmental quality improvement efforts. Multi-modality technologists were educated regarding the risks associated with misadministration and instructed to record data, such as ordering provider, modality, and source of error for all near-misses encountered each day. Statistical analyses were performed to identify the most common errors and their sources.

Over this five-month period, in 150,604 total imaging exams performed, 148 near miss-errors were identified in 145 imaging exams (0.1% of total exams), with 98% (145/148) ordering errors and 2% (3/148) protocol errors. 74% (107/145) of near-miss errors occurred in modalities utilizing ionizing radiation (CT or XR). 53% (77/145) of errors occurred on inpatients, 39% (56/145) on emergency room patients and 8% (12/145) on outpatients. The housestaff were responsible for 60% (87/145) of ordering errors, while 12% (18/145) originated from attendings and 28% (40/145) originated from physician extenders (nurse practitioners and physician assistants). Multiple services contributed to ordering errors, with the most from Internal Medicine (33%, 48/145) and Emergency Medicine (23%, 33/145). The ordering errors consisted of most frequently wrong body part (38%, 56/148), wrong side (17%, 25/148) and wrong contrast (14%, 21/148), but also included wrong patient (5%, 8/148) and duplicate (11%, 16/148). All errors were discovered and corrected before reaching the patient.

At our academic medical center, the majority of ordering errors occurred in modalities involving ionizing radiation and originated from housestaff providers in departments ordering high volume imaging. By identifying these major sources of error, we are better able to target information technology, educational and workflow-related solutions towards subsets of ordering providers to reduce the number of near-miss ordering errors and ultimately true miss-errors in the future.

Near-misadministration event analysis for imaging studies is important for reducing the number of true misadministration events leading to unnecessary radiation exposure and wasted resources.

Charalel, R, Drexler, I, Sanelli, P, Loftus, M, Hentel, K, Min, R, Near-Misadministration Events for Imaging Studies: A Detailed Analysis of Major Sources and Types of Errors.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14016264.html