Rubio Eva Ilse, Hogan Laurie
1 Both authors: Department of Radiology, Children's National Health System, 111 Michigan Ave NW, Washington, DC 20010.
AJR Am J Roentgenol. 2015 Nov;205(5):941-6. doi: 10.2214/AJR.15.14720.
The purpose of this study was to describe the utility of a two-person verification system (Rad Check) in successfully decreasing wrong-patient or wrong-study errors.
In this retrospective study performed at a tertiary-care pediatric hospital, monthly radiology incident reports from January 2009 through December 2014 were reviewed for documentation of wrong-patient or wrong-study events. The date, imaging modality, nature of the event, and number of imaging studies for this time period by year were recorded and analyzed. These data were tracked before and after implementation of the two-person verification system in July 2012.
Over 72 months, 45 reported wrong-patient or wrong-study events were confirmed. The data were analyzed before and after implementation of a two-person verification system implemented in July 2012, midway through the study period. Over the first 42 months, 36 wrong-patient or wrong-study occurrences were identified, corresponding to an average of one error every 35 days, with the number of days between events ranging from 3 to 150. After implementation of the verification process, nine events were documented over 30 months, corresponding to an average of one error every 101 days, with the maximum number of days between events exceeding 410.
Wrong-patient or wrong-study events can be significantly reduced by utilizing a brief two-person verification approach. More robust documentation of these events is warranted so that individual institutions can assess the incidence of these events within their own department and develop tailored plans to prevent these errors.
本研究旨在描述双人核查系统(Rad Check)在成功减少患者错误或检查错误方面的效用。
在一家三级儿科医院进行的这项回顾性研究中,对2009年1月至2014年12月的月度放射科事件报告进行审查,以记录患者错误或检查错误事件。记录并分析该时间段内每年的日期、成像方式、事件性质以及成像检查数量。在2012年7月实施双人核查系统之前和之后对这些数据进行跟踪。
在72个月期间,共确认了45起报告的患者错误或检查错误事件。对在研究期间中途即2012年7月实施双人核查系统之前和之后的数据进行分析。在前42个月中,共发现36起患者错误或检查错误事件,平均每35天出现一次错误,事件间隔天数为3至150天。实施核查流程后,在30个月内记录了9起事件,平均每101天出现一次错误,事件间隔天数最多超过410天。
采用简短的双人核查方法可显著减少患者错误或检查错误事件。有必要对这些事件进行更完善的记录,以便各机构能够评估其所在部门内这些事件的发生率,并制定针对性的计划来预防这些错误。