Background: Safety incident reporting is essential in medical imaging (MI) departments due to the fast-paced environment and high patient volume. However, there is an evident knowledge gap in the identification and investigation of contributing factors to incidents reports in MI departments. The objective of this study was to investigate the following rates of incident reporting in a MI department at a large academic health sciences centre: departmental incident rate, incident rates per imaging modality, and incident rates per incident type. Characteristics associated with the most frequently occurring incident types were examined to identify opportunities for quality improvement.
Methods: This observational, retrospective study collected approximately 665 MI incident reports submitted by staff between July 2018 and July 2019. Individual incident reports were categorized according to imaging modality and incident type. Subcategories of the top four incident types were also created to identify possible contributory factors based on the staff member's safety incident report submission.
Results: The safety incident rate for the entire medical imaging department was 0.263%. The safety incident reporting rate was calculated (# of incidents reported per modality total/ # of completed exams in that modality x 100%) for each modality and varied from 0.113 to 1.26%. The four highest safety incident rates were from adverse drug reaction (ADR) (21.5%), followed by delay in care/treatment (18.9%), identification/documentation/order (18.5%) and extravasation (11.4%). Possible contributory factors involved transfer of accountability (TOA)/communication barriers, and incorrect ordering information. Further analysis was also completed to assess whether patients that experienced an ADR or extravasation incident followed the correct protocols.
Discussion: This study demonstrated the importance of how analysis of incident report data can be used to uncover opportunities for quality improvement in the medical imaging department. However, more information must be collected at the time of safety incident report submission to allow for quality improvement. Investigators hope that by future standardization of safety incident reporting, with the increased use of drop-down menus to capture more open-ended responses, corrective strategies can be implemented to address safety concerns in MI departments. In comparison to incident reporting rates published in similar studies, there may be a significant underrepresentation of safety incident reports filed from underreporting. Reducing barriers to reporting is essential in improving the effectiveness of the current safety incident reporting system.
Keywords: Adverse drug reaction; Delay in care/treatment; Extravasation; Medical imaging; Quality improvement; Safety incident reporting; Transfer of accountability.
Copyright © 2020. Published by Elsevier Inc.
Mansouri M, Aran S, Harvey HB, Shaqdan KW, Abujudeh HH. Mansouri M, et al. J Magn Reson Imaging. 2016 Apr;43(4):998-1007. doi: 10.1002/jmri.25055. Epub 2015 Oct 20. J Magn Reson Imaging. 2016. PMID: 26483127
Tighe CM, Woloshynowych M, Brown R, Wears B, Vincent C. Tighe CM, et al. Accid Emerg Nurs. 2006 Jan;14(1):27-37. doi: 10.1016/j.aaen.2005.10.001. Accid Emerg Nurs. 2006. PMID: 16321534
Howell AM, Burns EM, Bouras G, Donaldson LJ, Athanasiou T, Darzi A. Howell AM, et al. PLoS One. 2015 Dec 9;10(12):e0144107. doi: 10.1371/journal.pone.0144107. eCollection 2015. PLoS One. 2015. PMID: 26650823 Free PMC article.
Williams H, Edwards A, Hibbert P, Rees P, Prosser Evans H, Panesar S, Carter B, Parry G, Makeham M, Jones A, Avery A, Sheikh A, Donaldson L, Carson-Stevens A. Williams H, et al. Br J Gen Pract. 2015 Dec;65(641):e829-37. doi: 10.3399/bjgp15X687877. Br J Gen Pract. 2015. PMID: 26622036 Free PMC article. Review.
Alves MFT, Carvalho DS, Albuquerque GSC. Alves MFT, et al. Cien Saude Colet. 2019 Aug 5;24(8):2895-2908. doi: 10.1590/1413-81232018248.23912017. Cien Saude Colet. 2019. PMID: 31389537 Review. English, Portuguese.
Jimenez YA, Lewis SJ. Jimenez YA, et al. Insights Imaging. 2023 Jul 14;14(1):121. doi: 10.1186/s13244-023-01470-1. Insights Imaging. 2023. PMID: 37450068 Free PMC article. Review.