Lessons from Medical Imaging Errors

2011-07-14
 

Avoiding medical imaging errorsA recent study in Pennsylvania highlights some of the common errors made in the medical imaging world.

The study, summarized in this article from HealthImaging.com, reports that of the over 650 radiology mistakes reported to the Pennsylvania Patient Safety Authority (PPSA),

  • 50 percent were wrong-procedure or wrong-test errors.
  • 30 percent were related to wrong-patient errors.
  • 20 percent were wrong-site errors.

The break down by discipline:

  • 45 percent were x-ray errors.
  • 17.6 percent were CT errors.
  • 15 percent were mammography errors.
  • The remaining were errors in MRI, ultrasound, PET scan, DEXA scan, nuclear medicine, and interventional radiology.

Error reports are troubling to medical imaging professionals, but ultimately, they can be instructive. John Clarke, MD, clinical director of PPSA, says that the organization took the report to heart and will immediately begin to follow the Universal Protocol of the Joint Commission for surgery. This will involve clearly labeling surgery sites, taking a team “time out” immediately prior to a surgery to review procedures, multiple identifications of the patient, and other procedures.

According to Clarke, the Universal Protocols can also “be used to standardize procedures in other areas of care to ensure that patients are accurately identified and procedures correctly scheduled and performed across-the-board, not just in the operating room.” In other words, the Universal Protocols would — and should – be used in all medical imaging suites.

Following up on a previous post, we noted that it would not be too difficult to include radiation dosing tracking – another growing concern in the medical imaging world – alongside the implementation of Universal Protocols.

And, for medical imaging professionals who want to learn from each other, McKesson offers Horizon Study Share™. Horizon Study Share is a web-based application that improves the ability to collaborate with peers by providing thousands of accessible radiology reference cases for reference, training and decision support. See a demo for more information.

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