Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework

doi:10.1016/j.jacr.2018.10.015

. 2019 Mar;16(3):282-288.

doi: 10.1016/j.jacr.2018.10.015. Epub 2018 Dec 7.

Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework

Ronilda Lacson¹, Laila Cochon², Ivan Ip³, Sonali Desai⁴, Allen Kachalia⁴, Jack Dennerlein⁵, James Benneyan⁶, Ramin Khorasani³

Affiliations

¹ Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address: rlacson@partners.org.
² Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
³ Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
⁴ Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
⁵ Center for Work, Health, and Wellbeing, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
⁶ Healthcare Systems Engineering Institute, Northeastern University, Boston, Massachusetts.

PMID: 30528933
PMCID: PMC7537148
DOI: 10.1016/j.jacr.2018.10.015

Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework

Ronilda Lacson et al. J Am Coll Radiol. 2019 Mar.

. 2019 Mar;16(3):282-288.

doi: 10.1016/j.jacr.2018.10.015. Epub 2018 Dec 7.

Authors

Ronilda Lacson¹, Laila Cochon², Ivan Ip³, Sonali Desai⁴, Allen Kachalia⁴, Jack Dennerlein⁵, James Benneyan⁶, Ramin Khorasani³

Affiliations

¹ Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address: rlacson@partners.org.
² Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts.
³ Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
⁴ Harvard Medical School, Boston, Massachusetts; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
⁵ Center for Work, Health, and Wellbeing, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
⁶ Healthcare Systems Engineering Institute, Northeastern University, Boston, Massachusetts.

PMID: 30528933
PMCID: PMC7537148
DOI: 10.1016/j.jacr.2018.10.015

Abstract

Purpose: The aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors.

Methods: The authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as "potential harm." Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause "potential harm" was compared for each step and sociotechnical factor using χ² analysis.

Results: Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P < .0001). The κ coefficient was 0.79.

Conclusions: Safety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.

Keywords: Patient safety; diagnostic errors; diagnostic imaging; sociotechnical factors.

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References

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[1] Kordbacheh H, Baliyan V, Serrao J, Gee MS, Yajnik V, Sahani DV, et al. Imaging in Patients with Crohn’s Disease: Trends in Abdominal CT/MRI Utilization and Radiation Exposure Considerations over a 10-Year Period. Inflamm Bowel Dis. 2017;23(6):1025–33. - PubMed

[2] Kordbacheh H, Baliyan V, Serrao J, Gee MS, Yajnik V, Sahani DV, et al. Imaging in Patients with Crohn’s Disease: Trends in Abdominal CT/MRI Utilization and Radiation Exposure Considerations over a 10-Year Period. Inflamm Bowel Dis. 2017;23(6):1025–33. - PubMed

[3] Smith-Bindman R, Miglioretti DL, Johnson E, Lee C, Feigelson HS, Flynn M, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996–2010. Jama. 2012;307(22):2400–9. - PMC - PubMed

[4] Smith-Bindman R, Miglioretti DL, Johnson E, Lee C, Feigelson HS, Flynn M, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996–2010. Jama. 2012;307(22):2400–9. - PMC - PubMed

[5] Ip IK, Raja AS, Seltzer SE, Gawande AA, Joynt KE, Khorasani R. Use of Public Data to Target Variation in Providers’ Use of CT and MR Imaging among Medicare Beneficiaries. Radiology. 2015;275(3):718–24. - PubMed

[6] Ip IK, Raja AS, Seltzer SE, Gawande AA, Joynt KE, Khorasani R. Use of Public Data to Target Variation in Providers’ Use of CT and MR Imaging among Medicare Beneficiaries. Radiology. 2015;275(3):718–24. - PubMed

[7] Huang HK, Arenson RL, Lou SL, Wong AW, Andriole KP, Bazzill TM, et al. Multimedia in the radiology environment: current concept. Comput Med Imaging Graph. 1994;18(1):1–10. - PubMed

[8] Huang HK, Arenson RL, Lou SL, Wong AW, Andriole KP, Bazzill TM, et al. Multimedia in the radiology environment: current concept. Comput Med Imaging Graph. 1994;18(1):1–10. - PubMed

[9] Sugimoto M Recent advances in visualization, imaging, and navigation in hepatobiliary and pancreatic sciences. J Hepatobiliary Pancreat Sci. 2010;17(5):574–6. - PubMed

[10] Sugimoto M Recent advances in visualization, imaging, and navigation in hepatobiliary and pancreatic sciences. J Hepatobiliary Pancreat Sci. 2010;17(5):574–6. - PubMed

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Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework

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Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework

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