Room: ePoster Forums
Purpose: Medical Errors and incidents in radiology receive little regulatory attention compared to those that occur in radiation oncology. Due to the smaller radiation doses associated with diagnostic and interventional imaging procedures, abnormal incidents have been of less concern and are not commonly reported. The significance of these events is examined from the perspectives of both regulatory and good practice standards. This presentation reviews standards and methods for the evaluation of incidents associated with diagnostic imaging, as well as definitions, root cause analysis and follow-up requirements for errors and medical events in imaging procedures.
Methods: A review of definitions for medical events/incidents and associated reporting and follow-up requirements for diagnostic medical errors is performed. Definitions by regulatory and advisory organizations are compared and contrasted. A sampling of reported events is presented and analyzed to elucidate common errors and associated root causes.
Results: Definitions of diagnostic medical errors and incidents by regulatory bodies, and accrediting and advisory organizations are found to span a broad range of reporting requirements. A general definition provided by the CRCPD, included as part of the Suggested State Regulations, has been adopted with a variety of modifications by approximately 24 states in the USA. State reporting requirements are not well standardized. Of 83 incidents reported to states in 2016 and 2017, 86 % originated from a single state. 48% of the reported events were attributed to exposures of the wrong anatomical site and 33% were attributed to examinations delivered to incorrect patients.
Conclusion: Errors in radiology imaging procedures undoubtedly occur. However, there is little reliable data available to determine specific error rates or root cause analysis. Inconsistent reporting requirements make it difficult to draw specific conclusions from existing data. Examples of procedures to enhance awareness and minimize errors may be translated from the radiation oncology community.