Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.

Pediatric Radiology
Hedieh KhalatbariRamesh S Iyer

Abstract

Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety. To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children's hospital that underwent root cause analysis and in which radiology was determined to play a contributing role. All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities. In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (2...Continue Reading

References

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