title: Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports.
abstract: The aim of this article is to describe the incidence and types of safety reports logged in the radiology safety incident reporting system in our emergency radiology section over an 8-year period. Electronic incident reporting system of our institute was searched for the variables in emergency radiology. All reports from April 2006 to June 2014 were included and deindentified. The following event classifications were investigated in radiography, CT, and MRI modalities: diagnostic test orders, ID/documentation/consent, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue, and diagnosis/treatment. A total of 881,194 emergency radiology examinations were performed during the study period, 1717 (1717/881,194 = 0.19 %) of which resulted in safety reports. Reports were classified into 14 different categories, the most frequent of which were "diagnostic test orders" (481/1717 = 28 % total incident reports), "medication/IV safety" (302/1717 = 18 % total incident reports), and "service coordination" (204/1717 = 12 % total incident reports). X-ray had the highest report rate (873/1717 = 50 % total incident reports), followed by CT (604/1717 = 35 % total incident reports) and MRI (240/1717 = 14 % total incident reports). Forty-six percent of safety incidents (789/1717) caused no harm and did not reach the patient, 36 % (617/1717) caused no harm but reached the patient, 18 % (308/1717) caused temporary or minor harm/ damage, and less than 1 % caused permanent or major harm/ damage or death. Our study shows an overall safety incident report rate of 0.19 % in emergency radiology including radiography, CT, and MRI modalities. The most common safety incidents were diagnostic test orders, medication/IV safety, and service coordination.
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, MA, 02114, USA. mmansouri1@partners.org.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Mansouri
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, MA, 02114, USA. kshaqdan@partners.org.
authors.forename: Khalid W
authors.initials: KW
authors.lastname: Shaqdan
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, MA, 02114, USA. aran.shima@mgh.harvard.edu.
authors.forename: Shima
authors.initials: S
authors.lastname: Aran
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Medical School, 55 Fruit Street, Founders Building, Suite 110, Boston, MA, 02114, USA. asraja@partners.org.
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, MA, 02114, USA. mlev@mgh.harvard.edu.
authors.forename: Michael H
authors.initials: MH
authors.lastname: Lev
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, MA, 02114, USA. Habujudeh@partners.org.
authors.forename: Hani H
authors.initials: HH
authors.lastname: Abujudeh
mesh_terms: D004630:Emergencies; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D016272:Occupational Health; D061214:Patient Safety; D058996:Quality Improvement; D011872:Radiology Department, Hospital; D012308:Risk Management
keywords: Emergency radiology; Incident report; Incident reporting system; Quality and safety; Quality improvement; Safety incident reporting system