Errors account for thousands of hospital deaths each year. And while mistake rates are lower in diagnostic imaging, Dutch radiologists have implemented a system to identify and mitigate as many as possible.
Researchers with University Medical Center Groningen in the Netherlands recently described a five-year experience using a new complication system to register errors in a tertiary care rad department. They looked at diagnostic, interventional and organizational mishaps, according to their review, published July 9 in the European Journal of Radiology. Perceptual mistakes, hemorrhage, and procedures on the wrong area of the body led all categories, respectively.
And although the group did not investigate whether the system reduced imaging errors or improved overall quality, they say the findings will push others in that direction.
“One of the novelties of the complication registration system … is the open departmental culture in which all complications are discussed in a standardized manner,” Marco Carrara, with the university’s medical imaging center, said in the study. “This may stimulate dissemination of this potential error reduction strategy to other institutions, and may provide valuable insight into the spectrum of errors that are encountered in diagnostic and interventional radiology from which lessons can be learned.”
The system employs a permanent radiologist to collect anonymized error cases that are then presented and discussed during an hour-long biannual meeting. All radiologists and residents are required to attend and learn from the errors, which are broken down into 13 types and can include everything from missed lung cancer on a CT scan to miscommunication of a critical finding.
Sixty-seven cases were included in their analysis, with most involving diagnostic errors (34 cases) and mistakes that did not harm patients (35).
Additionally, Carrara et al. recorded 19 interventional complications, with most (9) relating to symptomatic or major hemorrhage. Organizational missteps provided the fewest cases (14), and clinical process/procedure with wrong body part/side/site was the leading incident type in that category.
Most errors left patients unharmed, followed by 10 mild and moderate cases, six severe, five deaths, and one unknown. Interventional complications led to more significant harms compared to the other two error categories.
Nearly all subspecialties contributed cases over the five-year period, the authors noted. Most radiology departments already document and monitor interventional complications, but Carrara and colleagues say other errors should not go unexamined.
“Although future studies with larger sample sizes are required, these findings underline the importance of a departmental system that addresses all groups of radiologic complications rather than interventional complications only,” they concluded.