Carrie Phillips, Presenter: Nothing to Disclose

Karl N. Krecke MD, Abstract Co-Author: Nothing to Disclose

Anil Nicholas Kurup MD, Abstract Co-Author: Nothing to Disclose

Laura Tibor MBA, BEng, Abstract Co-Author: Nothing to Disclose

Sherrie L. Prescott RN, Abstract Co-Author: Nothing to Disclose

Robert E. Watson MD, PhD, Abstract Co-Author: Nothing to Disclose

We present  our experience with and rates of occurrence of sentinel events in a large multispecialty group practice. The use of denominators is important for benchmarking high-reliability radiology practice.

We reviewed our institutional database for sentinel events assigned to the Department of Radiology by the institution's quality management team from 2008-2013. Denominators were selected to reflect the total number of patient exams performed and unique patient visits in each year. Annual rates were computed for events per radiology exam performed and events per 10,000 unique patients. Each event represents a significant defect in care and defect rates were computed for sigma level. Events were stratified into inpatient vs outpatient, harm vs risk, and grouped by error type.

Seventy-nine sentinel events  were ascribed to the department over the six year period. Annually, a mean of 210,512 patients were examined in Radiology and an average of 937,214 examinations performed. Annual rate of sentinel event occurrence averaged 13.2 events (range: 8-19). Events occurred at a rate of 0.0014% for exam volumes (range: 0.0008 - 0.0020%) and 0.625 events per 10,000 unique patients (range: 0.40 - 0.91). These defects in care represent an average sigma level of 5.7 (range: 5.61 – 5.81). Of the 79 events, 43% were associated with patient harm and 57% with increased risk of harm. Fifty-four percent of events occurred in the outpatient setting, 41% inpatient, and 5% in the emergency department. We had one patient death due to equipment failure during an interventional procedure. Our areas of opportunity are in defects related to incorrect procedure or exam, medication misadministration, specimen mishandling, and delay in treatment.

Rates of significant care defects are low in our practice compared to manufacturing standards.  Yet, opportunities to improve patient care and safety remain.

Patient safety is a preeminent priority in Radiology. While we work toward a goal of error-free practice, "never" is a stretch goal. Benchmarking current rates among enlightened, self-reflective practices will help guide learning and support discovery of best practices. Adopting standard definitions and measures of defect rates is a valuable step toward benchmarking and process improvement.  

Phillips, C, Krecke, K, Kurup, A, Tibor, L, Prescott, S, Watson, R, Six Years of Radiology Sentinel Events: Rates and Opportunities.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14045428.html