title: How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center.
abstract: OBJECTIVE
  Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre.
  
  
  METHODS
  This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, 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.
  
  
  RESULTS
  A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death.
  
  
  CONCLUSIONS
  Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders.
  
  
  CONCLUSIONS
  • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA.
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, 02114, MA, USA.
authors.forename: Shima
authors.initials: S
authors.lastname: Aran
authors.affiliation: Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA.
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, 02114, MA, USA. haniabujudeh@gmail.com.|Department of Radiology, Cooper University Hospital of Rowan University, One Cooper Plaza, Camden, 08103, NJ, USA. haniabujudeh@gmail.com.
authors.forename: Hani H
authors.initials: HH
authors.lastname: Abujudeh
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D003287:Contrast Media / Q000009:adverse effects*; D006801:Humans; D011856:Radiographic Image Enhancement; D012308:Risk Management / Q000706:statistics & numerical data*; D014057:Tomography, X-Ray Computed / Q000009:adverse effects*
chemical_list: D003287:Contrast Media
keywords: CT incident reporting; CT quality and safety; Incident reporting rate; Safety incident reporting; Safety incident reporting system