title: Learning from incident reports in the Australian medical imaging setting: handover and communication errors.
abstract: OBJECTIVE
  To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence.
  
  
  METHODS
  71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging.
  
  
  RESULTS
  Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%).
  
  
  CONCLUSIONS
  The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.
  
  
  CONCLUSIONS
  Handover and communication errors are prevalent in medical imaging. System-wide changes that facilitate effective communication are required.
authors: Australian Patient Safety Foundation, Adelaide, Australia. natalie.hannaford@apsf.net.au
authors: N
authors: N
authors: Hannaford
authors: C
authors: C
authors: Mandel
authors: C
authors: C
authors: Crock
authors: K
authors: K
authors: Buckley
authors: F
authors: F
authors: Magrabi
authors: M
authors: M
authors: Ong
authors: S
authors: S
authors: Allen
authors: T
authors: T
authors: Schultz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001315:Australia; D002648:Child; D002675:Child, Preschool; D003142:Communication; D057210:Delayed Diagnosis / Q000517:prevention & control / Q000706:statistics & numerical data; D003951:Diagnostic Errors / Q000517:prevention & control; D003952:Diagnostic Imaging / Q000009:adverse effects*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007223:Infant; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D062209:Patient Handoff / Q000592:standards*; D061214:Patient Safety; D012017:Referral and Consultation / Q000592:standards; D018570:Risk Assessment; D014187:Transportation of Patients / Q000592:standards; D055815:Young Adult
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