Abstract
OBJECTIVE. The purpose of this study was to estimate the prevalence of reported nearmiss wrong-patient events in radiology at two large academic hospitals and its relation to imaging modality, clinical setting, and time of occurrence. MATERIALS AND METHODS. An institutional imaging report database was searched for reports between January 1, 2009, and May 30, 2013, that contained the phrases "incorrect patient" or "wrong patient." These imaging reports were categorized into either mislabeled or misidentified patient or wrong dictation or report events. The mislabeling-misidentification events involved patients whose images were incorrectly placed in another patient's folder. In wrong dictation or report events, a patient's images were placed in the correct imaging folder, but another patient's images were used in error for dictation of the report. The time to detect each of these events was also evaluated. RESULTS. Overall, 67 eligible reports were identified among 1,717,713 examinations performed during the study period. The estimated event rate was 4 per 100,000 examinations (mislabeling-misidentification, 52%; wrong dictation, 48%). The monthly mean of mislabeling- misidentification events was 0.7 (SD, 0.9) and of wrong dictation events was 0.6 (SD, 0.7). The median time for mislabeling-misidentification reports to be identified was 22 hours and for wrong dictation reports was 0 hours. Portable chest radiography was the modality involved in 69% (24/35) of reported mislabeling-misidentification and 44% (14/32) of wrong dictation events (p = 0.08); 43% (15/35) of mislabeling-misidentification and 28% (9/32) of wrong dictation events occurred during off hours; 63% (22/35) of mislabeling-misidentification and 56% (18/32) of wrong dictation events occurred in the inpatient setting. CONCLUSION. Despite use of the dual-identifier technique mandated by The Joint Commission, the number of near-miss mislabeled patient events for imaging tests and the delay in awareness of these events were substantial, especially for radiography.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 337-343 |
| Number of pages | 7 |
| Journal | American Journal of Roentgenology |
| Volume | 205 |
| Issue number | 2 |
| DOIs | |
| State | Published - Aug 1 2015 |
| Externally published | Yes |
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Keywords
- Medical errors
- Wrong-patient events
ASJC Scopus subject areas
- Radiology Nuclear Medicine and imaging
- Medicine(all)
Cite this
Evaluation of near-miss wrong-patient events in radiology reports. / Sadigh, Gelareh; Loehfelm, Thomas W; Applegate, Kimberly E.; Tridandapani, Srini.
In: American Journal of Roentgenology, Vol. 205, No. 2, 01.08.2015, p. 337-343.Research output: Contribution to journal › Article
}
TY - JOUR
T1 - Evaluation of near-miss wrong-patient events in radiology reports
AU - Sadigh, Gelareh
AU - Loehfelm, Thomas W
AU - Applegate, Kimberly E.
AU - Tridandapani, Srini
PY - 2015/8/1
Y1 - 2015/8/1
N2 - OBJECTIVE. The purpose of this study was to estimate the prevalence of reported nearmiss wrong-patient events in radiology at two large academic hospitals and its relation to imaging modality, clinical setting, and time of occurrence. MATERIALS AND METHODS. An institutional imaging report database was searched for reports between January 1, 2009, and May 30, 2013, that contained the phrases "incorrect patient" or "wrong patient." These imaging reports were categorized into either mislabeled or misidentified patient or wrong dictation or report events. The mislabeling-misidentification events involved patients whose images were incorrectly placed in another patient's folder. In wrong dictation or report events, a patient's images were placed in the correct imaging folder, but another patient's images were used in error for dictation of the report. The time to detect each of these events was also evaluated. RESULTS. Overall, 67 eligible reports were identified among 1,717,713 examinations performed during the study period. The estimated event rate was 4 per 100,000 examinations (mislabeling-misidentification, 52%; wrong dictation, 48%). The monthly mean of mislabeling- misidentification events was 0.7 (SD, 0.9) and of wrong dictation events was 0.6 (SD, 0.7). The median time for mislabeling-misidentification reports to be identified was 22 hours and for wrong dictation reports was 0 hours. Portable chest radiography was the modality involved in 69% (24/35) of reported mislabeling-misidentification and 44% (14/32) of wrong dictation events (p = 0.08); 43% (15/35) of mislabeling-misidentification and 28% (9/32) of wrong dictation events occurred during off hours; 63% (22/35) of mislabeling-misidentification and 56% (18/32) of wrong dictation events occurred in the inpatient setting. CONCLUSION. Despite use of the dual-identifier technique mandated by The Joint Commission, the number of near-miss mislabeled patient events for imaging tests and the delay in awareness of these events were substantial, especially for radiography.
AB - OBJECTIVE. The purpose of this study was to estimate the prevalence of reported nearmiss wrong-patient events in radiology at two large academic hospitals and its relation to imaging modality, clinical setting, and time of occurrence. MATERIALS AND METHODS. An institutional imaging report database was searched for reports between January 1, 2009, and May 30, 2013, that contained the phrases "incorrect patient" or "wrong patient." These imaging reports were categorized into either mislabeled or misidentified patient or wrong dictation or report events. The mislabeling-misidentification events involved patients whose images were incorrectly placed in another patient's folder. In wrong dictation or report events, a patient's images were placed in the correct imaging folder, but another patient's images were used in error for dictation of the report. The time to detect each of these events was also evaluated. RESULTS. Overall, 67 eligible reports were identified among 1,717,713 examinations performed during the study period. The estimated event rate was 4 per 100,000 examinations (mislabeling-misidentification, 52%; wrong dictation, 48%). The monthly mean of mislabeling- misidentification events was 0.7 (SD, 0.9) and of wrong dictation events was 0.6 (SD, 0.7). The median time for mislabeling-misidentification reports to be identified was 22 hours and for wrong dictation reports was 0 hours. Portable chest radiography was the modality involved in 69% (24/35) of reported mislabeling-misidentification and 44% (14/32) of wrong dictation events (p = 0.08); 43% (15/35) of mislabeling-misidentification and 28% (9/32) of wrong dictation events occurred during off hours; 63% (22/35) of mislabeling-misidentification and 56% (18/32) of wrong dictation events occurred in the inpatient setting. CONCLUSION. Despite use of the dual-identifier technique mandated by The Joint Commission, the number of near-miss mislabeled patient events for imaging tests and the delay in awareness of these events were substantial, especially for radiography.
KW - Medical errors
KW - Wrong-patient events
UR - http://www.scopus.com/inward/record.url?scp=84938689628&partnerID=8YFLogxK
UR - http://www.scopus.com/inward/citedby.url?scp=84938689628&partnerID=8YFLogxK
U2 - 10.2214/AJR.14.13339
DO - 10.2214/AJR.14.13339
M3 - Article
C2 - 26204284
AN - SCOPUS:84938689628
VL - 205
SP - 337
EP - 343
JO - American Journal of Roentgenology
JF - American Journal of Roentgenology
SN - 0361-803X
IS - 2
ER -