Radiology personnel at two large academic hospitals hewed to the Joint Commission’s mandated “dual-identifier” technique to avoid misidentifying patients and/or wrongly dictating reports—but still created a number of near-miss patient events.

The close calls, which were caught and reported before harm was done, occurred at the rate of 4 per 100,000 over four and a half years.

Of these, 52 percent were of the mislabeling-misidentification type, indicating instances in which patients’ images were inadvertently placed in the folders of other patients. The other 48 percent involved reports dictated from other patients’ images.

A study report detailing the particulars is running in the August edition of the American Journal of Roentgenology.

Gelareh Sadigh, MD, and colleagues in the radiology department at Emory University arrived at their findings by searching an institutional database for radiology reports containing the phrases “incorrect patient” or “wrong patient.”

From 1.7 million imaging exams conducted during the study period, the team found 67 with problems. The monthly mean of mislabeling-misidentification events was 0.7 and of wrong dictation events, 0.6.

Portable chest x-rays were far and away the most prone to troubles in both types of errors.

“[A]ccording to our risk management office, none of the events resulted in malpractice issues,” they write. “However, a review of patients’ charts revealed that in only one case—a wrong dictation event in 2009—the start of the patient’s treatment was delayed, but there were no complications. The other cases were true near-miss wrong-patient events.”

Among the limitations of the study were that the near-miss events may have been marked with phrases other than the two the authors used in their database searches. This may mean they captured only a few of the events that actually occurred.

The authors conclude that the number of reported near-miss mislabeling events for imaging tests was “considerable”—and that delays in identifying these events, which they also documented, only increase the concern.

Many of these events “may have been under-reported,” they write. “Efforts should be made to improve systems learning and timely reporting of such events. Efforts should also be directed at using safety best practices and technologic means to decrease the frequency of such events.”

The full study is posted online. 

Click here for more on the Joint Commission’s requirement on using two patient identifiers.