Incident reports related to tasks performed by radiological technologists: an analysis of ten years of incident reports.
In the past 10 years at our university hospital, 202 incident reports related to tasks performed by radiological technologists were posted. In order to investigate the causes and trends of these incidents, we classified the incident reports into four groups based on the event content, level of harm caused to the patient, years of experience of the concerned radiological technologist, and relevant departmental section. In the event content group, 'a malfunctioning device' was the most common event (26.2%), whereas the other events were 'wrong examination procedure or therapy' (15.3%), 'patient fall' (10.9%), 'procedure-patient mismatch' (8.4%), 'accidental removal of patients' tubes or other intravenous devices' (7.9%), and 'bringing metallic material into the magnetic resonance imaging (MRI) room' (7.4%). In the level of harm caused to the patient group, level one events occurred frequently. Radiological technologists with 6-16 years of experience reported incidents most frequently. With regard to the relevant departmental section where the incidents occurred, departments with the highest number of reports were ranked as follows in descending order: general X-ray examination section, MRI section, radiation therapy section, nuclear medicine (NM) section, computed tomography (CT) section, angiography section, and fluoroscopy section. The following events in each corresponding section require careful monitoring: patient fall in the general X-ray examination section and NM section, bringing metallic material into the MRI room, malfunctioning devices in the radiation therapy section, accidental removal of the patient's tubes in the CT section, incorrect handling of the automatic contrast medium injector in the angiography section, and damage of device or article in the fluoroscopy section.
Department of Radiology, Hospital Division of Medical Technology, Kumamoto University Hospital; Graduate School of Health Sciences, Kumamoto University.
Masahiro
M
Hashida
Junji
J
Shiraishi
D000059:Accidents / Q000706:statistics & numerical data*; D000792:Angiography; D006801:Humans; D007564:Japan; D008279:Magnetic Resonance Imaging; D012308:Risk Management; D013679:Technology, Radiologic; D014057:Tomography, X-Ray Computed