Patient Safety Topics
:
Radiology, Universal Protocol
Overview

Multiple failed organizational and departmental processes may lead to wrong-patient, wrong-procedure, wrong-side, and wrong-site errors in radiology services. Implementing and enforcing policies that address patient identification and procedure verification processes to prevent errors, as well as ensuring that staff are continually trained, provides radiology services with opportunities for improvements that not only can be observed by providers but can be expected by patients.

Key Data and Statistics

In 2009, the Pennsylvania Patient Safety Authority received reports of 652 events specifically related to wrong-procedure or test (50%), wrong-patient (30%), wrong-side (15%), and wrong-site (5%) radiology errors. Predominant testing modalities reported to the Authority included radiography (45%), computed tomography (CT) scan (18%), mammography (15%), magnetic resonance imaging (MRI) (6%), and ultrasound (5%). 

In response to a request from a Pennsylvania healthcare facility for a more recent analysis of wrong radiology safety events, analysts queried the Authority's reporting database for reports of wrong radiology events using criteria similar to that used to analyze the 2009 data. Analysts' review of the event data identified almost 1,000 wrong radiology imaging events reported during a 12-month period.

 Reports of Wrong Radiology Events

Figure. Wrong Radiology Events Along the Medical Imaging Care Continuum

Excerpted from:
Field C. Adapting verification processes to prevent wrong radiology events. Pa Pat Saf Advis 2018 Sep [cited 2018 Sep 20]. http://patientsafety.pa.gov/ADVISORIES/Pages/201809_WrongSiteRadiology.aspx.
Applying the universal protocol to improve patient safety in radiology services. Pa Pat Saf Advis 2011 Jun [cited 2018 Sep 20]. http://patientsafety.pa.gov/ADVISORIES/Pages/201106_63.aspx.

Educational Tools

Sample Policy: Correct Patient Identification and Procedure Verification for Radiology Services
This sample policy can be adapted by facilities to ensure that the intended radiology procedure(s) are performed on the correct patient.

Radiology Services–Patient and Procedure Verification Checklist
This sample assessment tool may be used by radiologic technologists or other radiology staff to ensure that the correct patient, the correct procedure, and the correct side or site have been identified before performing radiographic procedures and whether patients meet specific qualifications for radiographic studies.

Learning from Adverse Events: An Inservice Opportunity for Radiology Staff
Radiology leaders and educators are encouraged to use the statewide reported events provided in this module as a teaching tool for staff to ensure that appropriate safety policies, procedures, and systems are in place.

Example: Radiology Exam Verification and Time Out Form
This example of a two-person radiology exam verification and time out checklist includes suggested elements for verifying patient identification and intended radiologic study.

Example: Two-Person Verification Form
Facilities may find this two-person radiology verification form useful in settings where typical procedural time-out processes may be challenging (e.g., portable radiologic imaging in a critical care unit).

Multimedia

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Advisory Articles
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