Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands.
Medical Imaging Center, Department of Radiology, Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, the Netherlands.
Eur J Radiol. 2020 Sep;130:109167. doi: 10.1016/j.ejrad.2020.109167. Epub 2020 Jul 9.
To describe and evaluate our initial 5-year experience with a new complication registration system for errors in radiology.
This study reviewed all cases that were submitted to a new complication registration system of a tertiary care radiology department between 2015-2019.
Sixty-seven cases were included. In the group of diagnostic complications/errors (n = 34), there were 21 perceptual errors and 13 cognitive errors. This 61.8 % (21/34) perceptual error rate was not significantly different (P = 0.297) from the 70 % perceptual error rate known from previous literature. In the group of interventional complications (n=19), most cases (47.4 % [9/19]) concerned symptomatic or major hemorrhage. In the group of organizational complications/errors (n=14), the leading incident type according to the International Classification System for Patient Safety was clinical process/procedure with wrong body part/side/site as subclassification (35.7 % [5/14]). Harm severities were none (n=35), mild (n=10), moderate (n=10), severe (n=6), death (n=5), and unknown (n=1). Harm severity of interventional complications was significantly higher (P < 0.05) than that of organizational complications, while there were no significant differences in harm severities between other groups of complications.
It is feasible to implement the radiologic complication registration system that was described in this study. Perceptual mistakes, hemorrhage, and procedures on the wrong body part/side/site dominated in the categories of diagnostic, interventional, and organizational complications/errors, respectively, and these should be the topic of vigilance in clinical practice and further research. Future studies are also required to determine whether this complication registration system reduces radiologic errors and improves healthcare quality.
描述并评估我们在放射科错误新并发症登记系统方面的最初 5 年经验。
本研究回顾了 2015 年至 2019 年间三级保健放射科新并发症登记系统中提交的所有病例。
共纳入 67 例。在诊断并发症/错误组（n=34）中，有 21 例感知错误和 13 例认知错误。这种 61.8%（21/34）的感知错误率与先前文献中已知的 70%的感知错误率无显著差异（P=0.297）。在介入并发症组（n=19）中，大多数病例（47.4%[9/19]）涉及症状性或大出血。在组织并发症/错误组（n=14）中，根据国际患者安全分类系统，主要事件类型为临床过程/程序，以错误的身体部位/侧/部位为亚分类（35.7%[5/14]）。危害严重程度为无（n=35）、轻度（n=10）、中度（n=10）、重度（n=6）、死亡（n=5）和未知（n=1）。介入并发症的危害严重程度显著高于组织并发症（P<0.05），而其他并发症组之间的危害严重程度无显著差异。
实施本研究中描述的放射科并发症登记系统是可行的。感知错误、出血和错误身体部位/侧/部位的程序分别主导诊断、介入和组织并发症/错误的分类，这些应成为临床实践和进一步研究中警惕的主题。还需要进一步的研究来确定这种并发症登记系统是否能减少放射科错误并提高医疗保健质量。
