title: JOURNAL CLUB: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports.
abstract: OBJECTIVE
  The purpose of this study was to estimate the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals and its relation to imaging modality, clinical setting, and time of occurrence.
  
  
  METHODS
  An institutional imaging report database was searched for reports between January 1, 2009, and May 30, 2013, that contained the phrases "incorrect patient" or "wrong patient." These imaging reports were categorized into either mislabeled or misidentified patient or wrong dictation or report events. The mislabeling-misidentification events involved patients whose images were incorrectly placed in another patient's folder. In wrong dictation or report events, a patient's images were placed in the correct imaging folder, but another patient's images were used in error for dictation of the report. The time to detect each of these events was also evaluated.
  
  
  RESULTS
  Overall, 67 eligible reports were identified among 1,717,713 examinations performed during the study period. The estimated event rate was 4 per 100,000 examinations (mislabeling-misidentification, 52%; wrong dictation, 48%). The monthly mean of mislabeling-misidentification events was 0.7 (SD, 0.9) and of wrong dictation events was 0.6 (SD, 0.7). The median time for mislabeling-misidentification reports to be identified was 22 hours and for wrong dictation reports was 0 hours. Portable chest radiography was the modality involved in 69% (24/35) of reported mislabeling-misidentification and 44% (14/32) of wrong dictation events (p = 0.08); 43% (15/35) of mislabeling-misidentification and 28% (9/32) of wrong dictation events occurred during off hours; 63% (22/35) of mislabeling-misidentification and 56% (18/32) of wrong dictation events occurred in the inpatient setting.
  
  
  CONCLUSIONS
  Despite use of the dual-identifier technique mandated by The Joint Commission, the number of near-miss mislabeled patient events for imaging tests and the delay in awareness of these events were substantial, especially for radiography.
authors.affiliation: 1 Department of Radiology and Imaging Sciences, Winship Cancer Institute, Emory University, 1701 Uppergate Dr NE, Atlanta, GA 30322.
authors.forename: Gelareh
authors.initials: G
authors.lastname: Sadigh
authors.affiliation: 1 Department of Radiology and Imaging Sciences, Winship Cancer Institute, Emory University, 1701 Uppergate Dr NE, Atlanta, GA 30322.
authors.forename: Thomas
authors.initials: T
authors.lastname: Loehfelm
authors.affiliation: 1 Department of Radiology and Imaging Sciences, Winship Cancer Institute, Emory University, 1701 Uppergate Dr NE, Atlanta, GA 30322.
authors.forename: Kimberly E
authors.initials: KE
authors.lastname: Applegate
authors.affiliation: 1 Department of Radiology and Imaging Sciences, Winship Cancer Institute, Emory University, 1701 Uppergate Dr NE, Atlanta, GA 30322.|2 School of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA.
authors.forename: Srini
authors.initials: S
authors.lastname: Tridandapani
mesh_terms: D003951:Diagnostic Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D006801:Humans; D010355:Patient Identification Systems; D011873:Radiology Information Systems; D014481:United States
keywords: medical errors; wrong-patient events