pennsylvania patient safety advisory many radiology errors caused by failed protocols

As part of its quarterly Pennsylvania Patient Safety Advisory released in June, the Pennsylvania Patient Safety Authority revealed that it received 652 reports of radiology errors from health care facilities in 2009, the latest period studied. A review of those events found that specific failed protocols such as inaccurate scheduling, patient misidentification and failure to verify procedures exposed patients to potential harm.

According to the report, 50 percent of the radiology errors involved the wrong procedure or test being administered. Another 30 percent of the events involved wrong patient procedures, 15 percent involved procedures being performed on the correct body part but on the wrong side, and 5 percent involved wrong-site procedures.

In medical malpractice cases involving diagnostic errors such as a missed diagnosis, a delayed diagnosis or a failure to diagnose an illness altogether, a radiology error is often a primary cause. Even if a radiology error doesn’t result in a diagnostic error, an unnecessary or botched radiological procedure exposes the patient to radiation and can carry other risks to the patient.

Pennsylvania Patient Safety Authority recommends error-reduction strategies to prevent radiology errors

In recommending steps hospitals and health care facilities should take to reduce the risk of radiology errors, the Authority cited the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery outlined by the nonprofit accreditation and certification organization the Joint Commission. Although the Universal Protocol is most commonly associated with preventing surgical errors, the Authority points out that the principles are transferrable to other disciplines where unintended procedures and complications are a problem.

“These protocols, while targeted toward preventing surgery mistakes, can be used to standardize procedures in other areas of care to ensure that patients are accurately identified and procedures correctly scheduled and performed across-the-board, not just in the operating room,” says the clinical director of the Authority. “An assessment tool, sample policy and teaching module of events with learning points are also available for patient safety officers to determine where their facility stands in regard to the likelihood of these events happening in their facility.”

Source: Pennsylvania Patient Safety Authority press release, “Failed Organizational and Departmental Processes May Lead to Wrong-Patient, Wrong-Procedure, Wrong-Side and Wrong-Site Errors in Radiology Services,” June 1, 2011

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