Lessons learned: 3 ways to limit wrong-patient events

In a recent study published in the American Journal of Roentgenology, faculty from Emory University’s Winship Cancer Institute examined the frequency of wrong-patient events. The number of near-misses was “considerable,” they concluded, and there was definite room for improvement.

“While the absolute number of such events is very small (4 for 100,000), we ideally strive for zero,” Srini Tridandapani, MD, a co-author of the study, told RadiologyBusiness.com. “Our goal is to learn from these mistakes and to prevent them from happening.”

The study found that these events were largely the result of mislabeling or wrong dictation, and strategies were adopted to limit them from taking place in the future. The strategies were based on feedback from radiologists and technologists, and discussed by the radiology department’s quality and safety committee.

Some of those adopted strategies included:

1. Implement a radiology information system

Putting a radiology information system in place helped the department cut down on errors related to wrong dictation by automating certain parts of the process, explained Kimberly Applegate, MD, another co-author of the study.

“In the past, a radiologist had to manually bring up the images for a patient and manually bring up the dictation reporting system for that patient,” Applegate told RadiologyBusiness.com. “Errors can be made here because the radiologist can bring up images from one patient and dictate into another patient’s chart. After implementation of a radiology information system, the dictation platform opens simultaneously with the opening of the patients’ images, and therefore, reduces the number of wrong patient reports due to wrong dictation."

2. Document all events and send them to a committee

Technologists were advised to document wrong-patient events when they occurred, filling in key information such as the date, location, technologist name, patient name and what specifically happened. These reports were then sent regularly to a committee for quality and safety for evaluation, so future events could be avoided.

“We encourage a culture of lifelong learning,” Applegate said. “Without acknowledging our safety events, we cannot learn from them and improve the work we do and how we care for our patients.”

3. Keep technologist-radiologist communication strong

In addition to documenting events, Applegate said, technologists were also instructed to inform the radiologist responsible for interpretation when any sort of wrong-patient event occurred. It is then up to the radiologist to assess the situation and decide if further imaging or repeat imaging are necessary.

Any extra imaging that results from a wrong-patient event is then free of charge.