June 2011
Need an MRI? Mammogram? CT Scan?
Radiology
No

 

If you need to have an MRI, mammogram, CT scan (sometimes called a CAT scan) or some other radiology service, it is important for you to make sure you receive the correct test on the correct body part so that you are not exposed to more radiation than is necessary. The Pennsylvania Patient Safety Authority recently reviewed 652 reports of events specifically related to radiology services. Half of the reports showed that patients received the wrong procedure or test; 30% of the reports showed the wrong patient was given the procedure; 15% showed the wrong side was done for the procedure, and in five percent of the reports the wrong site was targeted for the procedure.

Failed Processes

After reviewing the 652 event reports, several failed processes were identified for causing the four wrong events (wrong patient, wrong procedure, wrong side and wrong site). The failed processes were catergorized  as follows for causing the events:

  • Incorrect order or requisition entry
  • Failure to confirm patient identity
  • Failure to follow site and procedure verification or procedure qualification processes

Real Pennsylvania Cases

Wrong Orders or Requisition Entry (50% of wrong events)

A physician ordered bilateral hands and wrist x-rays. The registrar incorrectly entered orders for bilateral hands and feet. The technician did not verify the physician's order and completed bilateral hands/wrists and feet x-rays.

In 50% of the wrong events reported patients were subjected to wrong radiology tests because of an incorrect order entry coming from patient care areas (e.g., floor, emergency department) or caused by personnel who selected the wrong option when filling out requisition forms. Wrong orders included order entries that did not specify whether a procedure was to be done with or without contrast and order specifications that were opposite of what was intended.

Mammograms

One of the most common studies inaccurately ordered or scheduled from the physician's office was mammograms. A total of 98 near-miss events (i.e., a medical event that could have harmed a patient, but did not due to chance, prevention or mitigation) were reported pertaining to the improper order, 59 (60%), or scheduling, 39 (40%), of mammogram services. Physicians ordered a screening rather than a diagnostic mammogram in 43 (73%) events, a diagnostic mammogram was ordered instead of a screening in 10 (17%) events, and in 6 (10%) events, the study improperly ordered was not specified.

What You, as a Patient, Can Do to Help Prevent These Mistakes
  • Your doctor should tell you what radiology procedure or study you need.  Make sure you write down the exact procedure and double check with your doctor that you wrote down the correct test. When you go for the test or procedure make sure to take your notes with you and confirm with the technician what tests are being done. Be sure to include all details (e.g., with or without contrast).
  • If possible, take someone with you to your appointments so they can help verify the information and tests ordered.
  • When having any radiologic procedure be sure to ask for protective gear (e.g., thyroid guard and/or pelvic guard can be worn for extra precaution when receiving a mammogram).
Failure to Confirm Patient Identity (30% of wrong events)

Patient came into the hospital to have an ultrasound done. A [radiology] staff member went out to the waiting room to get an outpatient for a chest x-ray and called for "Mary." Mary got up and followed her to the x-ray department where the staff member did a two-view chest x-ray. The staff member did not verify the patient's last name or date of birth. It was the wrong Mary.

The events reported to the Authority consistently noted that technologists failed to use two forms of distinct patient identification (e.g., rather than using a patient's name and date of birth, for example, patients were identified using room numbers, or procedure or radiologic studies). Other identification mistakes happened when radiology staff took the wrong patient from a hospital room because the patient misunderstood the name called, staff were not actively engaged in the identification process, or the patient for whom a study was intended  had been transferred to another unit, and the new patient occupying the bed was taken for the radiologic study instead.

Requiring patients to actively respond to questions (i.e. "What is your name?") rather than passively confirming the patient's information (i.e. "Are you Jane Doe?") and accepting a "yes" or "no" answer or a head nod, can put a patient at risk for misidentification errors.

What You, as a Patient, Can Do to Help Prevent These Mistakes
  • Make sure when you are called from a waiting room for a procedure that you confirm with the person calling you your full name and birth date. Also confirm the procedure you are to have done and why.
  • If you are taken from a hospital room for a radiologic procedure, again make sure you are identified using your full name and birth date and NOT your room number. Also confirm the procedure you are to have done.
  • If you have other family members who use the healthcare facility for tests, make sure that you are not confused with that family member. Always state your full name and birth date to the healthcare worker.
Failure to Follow Site and Procedure Verification or Procedure Qualification Processes (20% of wrong events)

A patient arrived with physician order for an abdominal x-ray to view the kidneys, ureters and bladder (KUB) with other modifiers on the form, "left ulcer lower extremity rule out osteomyelitis." When the patient was questioned, he insisted on a history of abdominal pain and the need for KUB. A KUB was done. After the incident, the supervisor was notified. The doctor's office was called to clarify order. Left leg [radiograph] was needed, not KUB. The patient was called to return for correct films.

Problems with the wrong side or wrong site events usually were a result of inadequate verification. These events made up about 20% of the four wrong radiology events.

What You, as a Patient, Can Do to Help Prevent These Mistakes
  • Make sure you talk with your doctor and understand the exact procedure you are to have done. Write down the exact name of the procedure and body part to be studied. Ask your doctor to confirm what you wrote down. Take someone with you, if possible, to help confirm what you heard.

For more information on this article, click here or visit the Pennsylvania Patient Safety Authority.

©2018 Pennsylvania Patient Safety Authority