The advancement of medical imaging technologies, such as Picture Archiving and Communication Systems (PACS) and Radiology Information Systems (RIS), is contributing to a host of clinical advantages. At the top of that list of advantages are radiology risk management and improved safety – for patients and staff alike.
During the 2009 RSNA Scientific Assembly and Annual Meeting, Dr. Jonathan B. Kruskal shared insight on safety and risk management in radiology departments. We sat down with Dr. Kruskal, chairman of the Department of Radiology at Beth Israel Deaconess Medical Center in Boston, to learn how RIS can contribute to reduced errors.
How can RIS help reduce errors in clinical radiology departments?
RIS allow certain loops to be closed, such as communication of abnormal results and follow-up of recommendations for abnormal results. But it can also be used for and linked to facilitating a peer review process, a quality and safety reporting and management process, and minimizing variation in reports and communication to referring physicians through structured reporting. I believe that in the future, RIS will be an essential component for any quality program.
You spoke during RSNA 2009 on radiology risk management. What were some of the top points you made during your session?
During my RSNA talk, I covered radiological errors. The major points I made are that errors occur commonly. We all make mistakes, but it is essential to use analytic processes to turn each error into an opportunity for improvement.
I described a new error classification system that, instead of focusing on the human component, will bring in the spectrum of latent or organizational contributors and will place the patient at the center of this classification. The essential message is that when an error occurs, a variety of other minor contributors have also been set in motion to facilitate this error from taking place. Error detection systems are essential in order to manage errors, minimize the degree of harm, manage personnel involved and identify contributing factors so they can be eliminated.
What measures have been taken at Beth Israel Deaconess to reduce errors and improve radiology risk management?
At Beth Israel Deaconess, we have established a comprehensive program as was recently described in our manuscript, “Strategies for Establishing a Comprehensive Quality and Performance Improvement Program in a Radiology Department,” in RadioGraphics. We have a triple reporting system:
- The first is a web-based patient safety reporting system managed by our Health Care Quality Department in the hospital.
- The second is a mandatory peer-review process where each physician is expected to peer-review at least 5% of his or her prior year’s volumes – these are actively managed and audited.
- Lastly, is an intradepartmental web-based reporting system for all errors, be these technical or clinical.
It is our cultural expectation that all staff, be they technical, physician or trainees, participate and report all errors freely, including those that are near misses. These are all managed by our Quality Management Team, who audit and seek trends.
Can you offer a real-world example illustrating how errors were reduced through radiology risk management?
To reduce errors, we have a vigorous evaluation of all reported errors and link this to ongoing safety walkabouts and hazard analyses. All errors undergo root cause analysis, seeking to identify contributing causes. Any sentinel event undergoes a thorough root cause analysis with action plans and assigned accountable personnel to follow-up and ensure that this strategy is working.
A good example was a wrong joint injection under fluoroscopy. The error was immediately detected and reported, and disclosure was made to all relevant personnel, including an apology to the patient. A same-day visit to the site took place to identify exactly what happened, and a root cause analysis then took place 48 hours later.
At this analysis, the human factors were fully evaluated, from the decision to order the study to the interaction with our schedulers, office staff, technologists, sonographers, nurses, radiology fellow and radiology attending. We also looked at the contribution from the patient to identify any potential patient factors that may have contributed to this.
We then looked further at the latent contributors and identified a number of contributing factors to this error. Specifically, an unusual abbreviation was used in the requisition. All other steps were performed correctly, including performance of a time-out. However, the time-out demonstrated some variation in that the requisition was not read out aloud, but the patient ID, the perceived request and the location of the correct left third toe were all verified. The patient, indeed, even verified the procedure.
Latent contributors were that the section was understaffed (one staff member was out sick) and the attending had read over 170 cases before. The fellow was experienced and excellent, and therefore, the attending perceived no risk in working with this fellow. Both the fellow and the attending never had any prior similar experiences.
As a result of this root cause analysis, we have now established a new policy for not using even unfamiliar abbreviations when scheduling. We have also introduced a scripted pre-procedure time-out so that all elements of the time-out are not only documented, but described, and are all participated in, specifically in reading out the requisition for the study. Subsequent to this time, we have not had a wrong site procedure.
Looking ahead, how do you foresee technology advances allowing for even greater radiology risk management?
In terms of further reducing errors in radiology departments, several steps need to take place.
Beyond simply adhering to the Joint Commission requirements that all hospital systems have error reduction systems and perform vigorous root cause analyses, cultural shifts are required. All staff working in a department must view errors as important opportunities for analysis and identification of contributing factors. In addition, this cultural shift will require the free, anonymous and non-punitive reporting of errors so that opportunities for improvement can be identified.
The requirement that all trainees now undertake an outcomes project is a unique opportunity for training in this culture. We now expect each of our residents to undertake a month-long quality and safety rotation where they are exposed to the tools of quality and safety. They also undertake a project aimed at improving safety for all patients and staff in our department.
In addition, the ability of RIS to link to PACS and to allow peer-review, easy, auditable, manageable reporting of all events will facilitate this improvement. This could also be further improved by allowing dosage of radiation exposure to be continuously recorded within the studies. That way, when a study is ordered, the ordering physician is fully aware of what prior studies have been performed and what the patient’s prior exposure dose is.