title: Radiologic Safety Events Within a Pediatric Emergency Medicine Network.
abstract: OBJECTIVE
  The aim of this study was to describe the epidemiology of radiologic safety events using an analysis of deidentified incident reports (IRs) collected within a large multicenter pediatric emergency medicine network.
  
  
  METHODS
  This study is a report of a planned subanalysis of IRs that were classified as radiologic events. The parent study was performed in the PECARN (Pediatric Emergency Care Applied Research Network). Incident reports involving radiology were classified into subtypes: delay in test, delay in results, misread or changed reading, wrong patient, wrong site, or other. The severity of radiology-related incidents was characterized. Contributing factors were identified and classified as environmental, equipment, human (employee), information technology systems, parent or guardian, or systems based.
  
  
  RESULTS
  Two hundred three (7.0%) of the 2906 IRs submitted during the study period involved radiology. Eighteen of the hospitals submitted at least 1 IR and 15 of these hospitals reported at least 1 radiologic event. The most common type of radiologic event was misread/changed reading, which accounted for over half of all IRs (50.3%). Human factors were the most frequent contributing factor identified and accounted for 67.6% of all factors. The severity of events ranged from unsafe conditions to events with temporary harm that required hospitalization.
  
  
  CONCLUSIONS
  We described the epidemiology of radiology-related IRs from a large multicenter pediatric emergency research network. The study identified specific themes regarding types of radiologic errors, including the systems issues and the contributing factors associated with those errors. Results from this analysis may help identify effective intervention strategies to ameliorate the frequency of radiology-related safety events in the emergency department setting.
authors.affiliation: From the *Department of Pediatrics, Jacobi Medical Center, Bronx, NY; †Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI; ‡Division of Emergency Medicine, Children's National Medical Center, Washington, DC; §Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA; ∥Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; ¶Department of Pediatrics, University of Maryland, Baltimore, MD; #Department of Pediatrics, University of Utah, Salt Lake City, UT; and **Department of Pediatrics, Women and Children's Hospital of Buffalo, Buffalo, NY.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Blumberg
authors.forename: Prashant V
authors.initials: PV
authors.lastname: Mahajan
authors.forename: Karen J
authors.initials: KJ
authors.lastname: OʼConnell
authors.forename: James M
authors.initials: JM
authors.lastname: Chamberlain
authors.forename: Kathy N
authors.initials: KN
authors.lastname: Shaw
authors.forename: Richard M
authors.initials: RM
authors.lastname: Ruddy
authors.forename: Richard
authors.initials: R
authors.lastname: Lichenstein
authors.forename: Tomohiko
authors.initials: T
authors.lastname: Funai
authors.forename: Kathleen A
authors.initials: KA
authors.lastname: Lillis
mesh_terms: D002648:Child; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D061214:Patient Safety; D000070316:Pediatric Emergency Medicine / Q000706:statistics & numerical data*; D011871:Radiology / Q000706:statistics & numerical data*; D012308:Risk Management