Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Radiological Technology, The Michener Institute of Education at UHN, Toronto, Ontario, Canada.
Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Radiological Technology, The Michener Institute of Education at UHN, Toronto, Ontario, Canada.
J Med Imaging Radiat Sci. 2021 Mar;52(1):86-96. doi: 10.1016/j.jmir.2020.11.018. Epub 2020 Dec 25.
Safety incident reporting is essential in medical imaging (MI) departments due to the fast-paced environment and high patient volume. However, there is an evident knowledge gap in the identification and investigation of contributing factors to incidents reports in MI departments. The objective of this study was to investigate the following rates of incident reporting in a MI department at a large academic health sciences centre: departmental incident rate, incident rates per imaging modality, and incident rates per incident type. Characteristics associated with the most frequently occurring incident types were examined to identify opportunities for quality improvement.
This observational, retrospective study collected approximately 665 MI incident reports submitted by staff between July 2018 and July 2019. Individual incident reports were categorized according to imaging modality and incident type. Subcategories of the top four incident types were also created to identify possible contributory factors based on the staff member's safety incident report submission.
The safety incident rate for the entire medical imaging department was 0.263%. The safety incident reporting rate was calculated (# of incidents reported per modality total/ # of completed exams in that modality x 100%) for each modality and varied from 0.113 to 1.26%. The four highest safety incident rates were from adverse drug reaction (ADR) (21.5%), followed by delay in care/treatment (18.9%), identification/documentation/order (18.5%) and extravasation (11.4%). Possible contributory factors involved transfer of accountability (TOA)/communication barriers, and incorrect ordering information. Further analysis was also completed to assess whether patients that experienced an ADR or extravasation incident followed the correct protocols.
This study demonstrated the importance of how analysis of incident report data can be used to uncover opportunities for quality improvement in the medical imaging department. However, more information must be collected at the time of safety incident report submission to allow for quality improvement. Investigators hope that by future standardization of safety incident reporting, with the increased use of drop-down menus to capture more open-ended responses, corrective strategies can be implemented to address safety concerns in MI departments. In comparison to incident reporting rates published in similar studies, there may be a significant underrepresentation of safety incident reports filed from underreporting. Reducing barriers to reporting is essential in improving the effectiveness of the current safety incident reporting system.
由于医疗成像（MI）部门的快节奏环境和高患者量，安全事件报告至关重要。然而，在识别和调查 MI 部门事件报告的促成因素方面，存在明显的知识差距。本研究的目的是调查以下内容：在一家大型学术健康科学中心的 MI 部门，报告的安全事件发生率：部门事件发生率、每种成像方式的事件发生率和每种事件类型的事件发生率。检查与最常发生的事件类型相关的特征，以确定质量改进的机会。
这项观察性、回顾性研究收集了大约 665 份员工在 2018 年 7 月至 2019 年 7 月期间提交的 MI 事件报告。根据成像方式和事件类型对每份事件报告进行分类。还根据员工安全事件报告提交内容创建了前四种事件类型的子类别，以确定可能的促成因素。
整个医疗成像部门的安全事件发生率为 0.263%。每个模式的安全事件报告率（#报告的事件数/该模式完成的检查总数 x 100%）是根据每种成像方式计算得出的，从 0.113 到 1.26%不等。四个最高的安全事件发生率是由药物不良反应（ADR）引起的（21.5%），其次是延迟治疗/护理（18.9%）、识别/文件记录/医嘱（18.5%）和外渗（11.4%）。可能的促成因素涉及责任转移（TOA）/沟通障碍和不正确的医嘱信息。还完成了进一步的分析，以评估是否经历 ADR 或外渗事件的患者遵循了正确的协议。
本研究表明，分析事件报告数据可以用于发现医疗成像部门质量改进的机会。然而，必须在提交安全事件报告时收集更多信息，以便进行质量改进。研究人员希望通过未来安全事件报告的标准化，增加使用下拉菜单来获取更开放的回复，从而可以实施纠正策略来解决 MI 部门的安全问题。与类似研究中公布的事件报告率相比，提交的安全事件报告可能存在重大漏报。减少报告障碍对于提高当前安全事件报告系统的有效性至关重要。
