title: Reporting of Malposition of Lines and Tubes on Portable Radiographs Using Alert Notification of Critical Results.
abstract: Line malposition may result in significant iatrogenic complications. Awareness of the most common types of line malposition and the frequency of significant line-related complications is an important reminder to the radiologist to look carefully at all lines, especially the devices that are most commonly subject to malposition. Alert Notification of Critical Results (ANCR) are computer-generated pages or e-mails created by the radiologist to inform referring clinicians of significant radiologic findings. The alert is logged on the computer and all data are saved for future review. The primary purpose of the ANCR is to ensure that radiologists and clinicians have an effective and well-documented method of communication regarding significant imaging findings. A secondary purpose of ANCR data is the ability to review clinical practice. We have used the ANCR data to identify the frequency and types of line malpositions in the intensive care unit.
authors.affiliation: Division of Thoracic Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address: rmadan@partners.org.
authors.forename: Rachna
authors.initials: R
authors.lastname: Madan
authors.affiliation: Masters Student, Department of Biological Sciences, Mississippi College, Clinton, MS.
authors.forename: LaTia D
authors.initials: LD
authors.lastname: Peavy
authors.affiliation: Student, Division of Natural Science, Tougaloo College, Tougaloo, MS.
authors.forename: Breland
authors.initials: B
authors.lastname: Crudup
authors.affiliation: Division of Thoracic Imaging, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Andetta
authors.initials: A
authors.lastname: Hunsaker
mesh_terms: D002404:Catheterization / Q000009:adverse effects*; D005547:Foreign Bodies / Q000000981:diagnostic imaging*; D006801:Humans; D007049:Iatrogenic Disease / Q000517:prevention & control; D007362:Intensive Care Units; D007440:Intubation / Q000009:adverse effects*; D019095:Point-of-Care Systems; D011859:Radiography / Q000295:instrumentation*; D012308:Risk Management / Q000379:methods*