Monthly reviews improve adverse event reporting in interventional radiology

Monthly conference compliance reviews could improve unprompted adverse event (AE) reporting among interventional radiologists, according to a Penn Medicine study published Nov. 20 in the Journal of the American College of Radiology.

Reporting AEs in the medical space is critical to the success of hospital safety and risk management programs, first author Mandeep S. Dagli, MD, and colleagues wrote in JACR. However, while it’s “incumbent on physicians, as the leaders of the healthcare team, to be active participants in institutional and safety reporting,” research has suggested they’re largely unreliable reporters.

Dagli et al. noted that one study of California centers found just 1.7 percent of safety reports were filed by doctors themselves. Another, published in 2006, suggested point-blank that the majority of hospital-based AEs go unreported.

“Without sufficient knowledge of the AEs that occur, healthcare systems cannot identify common patterns of medical errors that point to systems and processes requiring change,” Dagli, an assistant professor of clinical radiology at Penn Medicine, and colleagues wrote. “In addition, without the timely knowledge of AEs, hospital risk management teams cannot take the appropriate actions to mitigate legal and financial risk.”

Interventions for improved risk reporting exist, they said, but they’ve been met with mixed results. For their work, the team evaluated five-year trends of a Penn Medicine program aimed at increasing institutional AE reporting.

Penn’s effort to increase reporting involved a monthly morbidity and mortality—or M&M—conference review that confirmed whether reported complications warranted additional AE reporting and whether those complications had been reported in a timely manner. Dagli et al. reviewed data starting in 2010, at the program’s inception.

Of 46,660 interventional radiology patient encounters, the authors said Penn physicians reported 1,160 major and minor complications and 462 reportable AEs. The percentage of reportable AEs increased between 2011 and 2015, from 67 percent to 98 percent, but the researchers found at least 24 percent of reportable AEs were potentially preventable.

“This estimate almost certainly represents a lower boundary for the true proportion of preventable events during the reviewed time period,” Dagli and colleagues wrote. “A number of complications, such as respiratory distress from preventable oversedation or aspiration, were difficult to identify confidently in retrospect from the available data and thus not included.”

The team’s results also suggested the incidence of AEs is strongly associated with procedure type, and a physician’s likelihood of reporting AE events was linked to the number of months that had passed since the initiation of the M&M program.

“With the increasing focus on improving healthcare quality as well as reducing the rising cost of health expenditures, healthcare provider organizations and third-party payers are placing greater importance on identifying potentially preventable admissions, readmissions and complications,” Dagli and colleagues wrote. “Our five-year experience suggests that a structured monthly M&M conference review on physician AE reporting can lead to significant improvement in unprompted interventional radiology physician self-reporting over time.”