TY - JOUR
T1 - Learning from incident reports in the Australian medical imaging setting
T2 - Handover and communication errors
AU - Hannaford, N.
AU - Mandel, C.
AU - Crock, C.
AU - Buckley, K.
AU - Magrabi, F.
AU - Ong, M.
AU - Allen, S.
AU - Schultz, T.
PY - 2013
Y1 - 2013
N2 - Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n5298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion: The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.
AB - Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n5298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion: The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.
UR - http://www.scopus.com/inward/record.url?scp=84873626117&partnerID=8YFLogxK
U2 - 10.1259/bjr.20120336
DO - 10.1259/bjr.20120336
M3 - Article
C2 - 23385994
AN - SCOPUS:84873626117
SN - 0007-1285
VL - 86
SP - 1
EP - 11
JO - British Journal of Radiology
JF - British Journal of Radiology
IS - 1022
ER -