Muench Gloria, Witham Denis, Rubarth Kerstin, Zimmermann Elke, Marz Susanne, Praeger Damaris, Wegener Viktor, Nee Jens, Dewey Marc, Pohlan Julian
Department of Radiology, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
Department of Cardiology, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charitéplatz 1, 10117, Berlin, Germany.
Insights Imaging. 2022 Nov 4;13(1):175. doi: 10.1186/s13244-022-01313-5.
Strategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisciplinary conferences (MDCs), radiologists and ICU physicians re-evaluate recent examinations. Structured bilateral feedback is provided to identify errors early. This study aims at investigating its impact on the occurrence of QM events (imaging-related errors). Standardised protocols of all MDCs from 1st of June 2018 through 31st of December 2019 were analysed with regard to categories of QM events (i.e. indication, procedure, report) and resulting consequences.
We analysed 241 MDCs with a total of 973 examinations. 14.0% ( = 136/973) of examinations were affected by QM events. The majority of events were report-related (76.3%, = 106/139, e.g. misinterpreted finding), followed by procedure-related (18.0%, = 25/139, e.g. technical issue) and indication-related events (5.8%, = 8/139, e.g. faulty indication). The median time until identification of a QM event (time to MDC) was 2 days (interquartile range = 2). Comparing the first to the second half of the intervention period, the incidence of QM events decreased significantly from 22.9% ( = 109/476) to 6.0% ( = 30/497) ( < 0.0001). Significance of this effect was confirmed by linear regression ( < 0.0001).
Establishing structured discussion and feedback between radiologists and intensive care physicians in the form of MDCs is associated with a statistically significant reduction in QM events. These results indicate that MDCs may be one suitable approach to timely identify imaging-related error.
The online version contains supplementary material available at 10.1186/s13244-022-01313-5.
识别影像相关错误并尽量减少其后果的策略在重症患者的管理中很重要。在重症监护病房（ICU）环境中实施了一项针对放射检查的新质量管理（QM）举措。在定期的多学科会议（MDC）中，放射科医生和ICU医生会重新评估近期的检查。提供结构化的双边反馈以尽早识别错误。本研究旨在调查其对QM事件（影像相关错误）发生情况的影响。分析了2018年6月1日至2019年12月31日所有MDC的标准化协议，涉及QM事件的类别（即指征、程序、报告）及产生的后果。
我们分析了241次MDC，共973次检查。14.0%（=136/973）的检查受到QM事件影响。大多数事件与报告相关（76.3%，=106/139，如发现解读错误），其次是与程序相关的事件（18.0%，=25/139，如技术问题）和与指征相关的事件（5.8%，=8/139，如指征错误）。识别QM事件的中位时间（至MDC的时间）为2天（四分位间距=2）。比较干预期的前半段和后半段，QM事件的发生率从22.9%（=109/476）显著降至6.0%（=30/497）（<0.0001）。线性回归证实了这种效应的显著性（<0.0001）。
以MDC的形式在放射科医生和重症监护医生之间建立结构化的讨论和反馈与QM事件在统计学上的显著减少相关。这些结果表明，MDC可能是及时识别影像相关错误的一种合适方法。
在线版本包含可在10.1186/s13244-022-01313-5获取的补充材料。
