Lost connection: When a safety improvement initiative fails to find support

Sometimes, the best laid plans for improving safe interaction with imaging equipment fail to gain traction.

That was the story from Jordan Swensson, MD, with the Department of Radiology and Imaging Services at the Indiana University School of Medicine, and colleagues, who authored a case study published online Jan. 5 in Academic Radiology recapping their attempt to coordinate a quality improvement plan within their institution.

The authors noted how the majority of published quality improvement articles either land in the successful project summary category or in the outlining of different approaches to quality improvement category.

“Largely missing from the literature are examples of the trials and tribulations of quality improvement efforts, including accounts of how such efforts have failed,” Swensson and colleagues wrote.

In response to a number of reported near misses at a large urban hospital, the authors developed a quality improvement project they called the MRI Safety Initiative. They planned to work within the radiology department and administer a pretest and a posttest, as well as presenting the safety module.

Initially, the radiology resident working to facilitate presenting the safety module emailed the clinical education department of the hospital and despite sending multiple messages through email and voicemail, they received no response over a three-month period.

Then, after presenting the module in January 2014 to nonradiolgist managers in the radiology department, the module team received word that the director of hospital risk management wanted to implement the module within the following week.

“What happened? As it turned out, there had been a safety incident in the MRI suite, in which a metallic gas canister had been brought into the MRI suite and had damaged the scanner, requiring it to be shut down for repairs,” the authors wrote.  “Fortunately, no patient had been present at the time of the incident. This incident had evidently ‘lit a fire’ beneath hospital administration, and an attitude of indifference had been supplanted by one of urgency.”

The module was distributed to hospital employees in February 2014. In April 2014, team members met with their original contact in the clinical education department to obtain the result of the pretest.

“The clinical educator informed him that the pretest had not been administered. When he asked why, no answer was forthcoming,” Swensson and colleagues wrote.

The clinical educator furnished the team with the posttest scores of the one-half of hospital employees who had completed the MRI safety education, but the quality improvement team could not demonstrate that completing the module had produced any improvement over baseline with that data alone.

The authors cite disparate goals between participants as the reason for the lack of traction for the MRI Safety Initiative.

“Although theory and methods are important, quality improvement is also a human endeavor, and as such, it is vital to attend to issues surrounding personality, institutional and social roles, and culture,” they concluded. “When quality improvement projects flourish, they can help improve the climate for future projects, and when they fail, they can provide important insights into personal and institutional factors that need to be corrected. The effective handling of quality improvement failures is itself an important form of quality improvement.”