Combining national radiology incident reporting systems with appropriate analysis and action can result in significantly safer healthcare. However, optimal deployment requires integration into a wider safety quality and risk management framework, according to an article in this month's Journal of American College of Radiology.
A recent World Health Organization report noted that unsafe patient care is ubiquitous and associated with significant morbidity and mortality throughout the world, wrote lead author D. Neil Jones of division of medical imaging at Flinders Medical Centre in Bedford Park, Australia. The rate of serious adverse events which result in permanent disability or contribute to or cause death is approximately two percent of hospital admissions, and studies show 40 to 50 percent of these adverse events are preventable, continued Jones.
Incident reporting can improve the quality of radiology processes and should include methods to detect and report different types of events. According to the World Alliance for Patient Safety, characteristics of a successful incident and reporting system are:
- Non-punitive, confidential, independent, timely and responsive;
- Expert analysis: reports are evaluated by experts who understand clinical circumstances and are trained to recognize underlying systems causes;
- Systems-oriented: recommendations focus on changes in systems, processes or products rather than target individual performance;
- Resourcing: expertise and adequate financial resources are available to allow for meaningful analysis of reports;
- Legal protection: reported de-identified information is given legal protection; and
- Data entry interface: system offers ease of use.
Other critical features include rapid dissemination of critical information and aggregation of incidents, adds Jones.
Jones also offered additional barriers to the establishment of radiology incident reporting systems. Physicians prefer electronic means of data entry, voluntary reporting and the ability to include near miss reporting whereas nurses favor mandatory systems limited to adverse event reporting. Nevertheless, physicians tend to submit few incident reports. Final limitations include detection of only a small percentage of target problems and a large number of mundane events with many incidents lacking statistical context, noted Jones.
The Australian model
Established in Australia in June 2006, the Radiology Events Register (RaER), a peer-driven, voluntary, anonymous and confidential reporting system that addresses many issues related to radiology incident reporting and provides a means of systemic data collection about adverse incidents and discrepancies in all areas of medical imaging, offered Jones.
The reporting system allows radiologists to enter data via a web interface and then classifies, analyzes and reports the data. By 2008, the system was made available to healthcare professionals and patients across the U.S. “Initially, case reports were written to highlight significant problems and recurring themes. Now that there is a larger collection of reports, a more detailed analysis of the data is in progress,” wrote Jones.
RaER addresses many barriers to incident reporting and engages physicians via integration with the Royal Australian and New Zealand College of Radiologists and administration by the national patient safety organization, summed Jones.