Quality initiatives: anatomy and pathophysiology of errors occurring in clinical radiology practice.
The Joint Commission requires development of comprehensive error detection systems that incorporate root cause analyses for all sentinel events. To prevent medical errors from occurring, there is a need for a readily available and easy-to-implement system for detecting, classifying, and managing mistakes. The wide spectrum of interrelated contributing factors makes the classification of errors difficult. Contributors to and causes of radiologic errors can be classified under latent and active failures. Latent failures include technical and system-related failures, with a radiology-specific subgroup of communication failures that includes documentation, inaccurate or incomplete information, and communication loop failures. Active failures may be ascribed to human failures (more specifically failure of execution of a task, inadequate planning, or behavior-related failures), patient-based failures, and external failures. Classification of an error should also include the impact of the error on the patient, staff, other customers, and radiology practice. Further considerations should include nonmedical impact of the error, including legal, social, and economic effects on both the patient and the system. Rather than focusing the investigation on blaming individuals for active failures, the primary effort should be to discover latent system failures that can be remedied at a departmental level. Such an error classification system will decrease the likelihood of future errors and diminish their adverse impact.
Brook
Olga R
OR
Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA. obrook@bidmc.harvard.edu
O'Connell
Anna Marie
AM
Thornton
Eavan
E
Eisenberg
Ronald L
RL
Mendiratta-Lala
Mishal
M
Kruskal
Jonathan B
JB
D003951:Diagnostic Errors / Q000145:classification* / Q000517:prevention & control*; D007591:Joint Commission on Accreditation of Healthcare Organizations; D011871:Radiology / Q000592:standards*; D012308:Risk Management / Q000379:methods* / Q000592:standards*; D014481:United States