Half of Pa. rad mistakes linked to wrong-procedure, test errors

Of 652 radiology mistakes reported to the Pennsylvania Patient Safety Authority (PPSA) in 2009, half were specifically related to wrong-procedure or test errors, according to a report published in the June issue of the Pennsylvania Patient Safety Authority. Another 30 percent of the incidents were related to wrong-patient errors.

The PPSA said the specific failed processes that placed patients in harm's way included order and scheduling innaccuracies, patient misidentification and innaccurate procedure verificiation processes.

Of all of the errors reported in the radiologic report, more than 45 percent were attributed to x-ray. CT was a distant second with 17.6 percent and mammography accounted for 15 percent of the errors. The PPSA also received reports of wrong events in MRI, ultrasound, nuclear medicine, interventional radiology, DEXA scan and PET.

While wrong-procedure or test errors topped the list, followed closely by wrong-patient errors, the PPSA also noted significant numbers of wrong-site errors (15 percent) and wrong-site radiology errors (5 percent), according to the organization.

“Patient identification issues are well recognized as a challenge in the healthcare arena,” said John Clarke, MD, clinical director of the PPSA in a statement. “When you’re dealing with a hospital setting it increases the risk of misidentification because of the numerous departments and healthcare personnel that are involved."

The authority recognized three categories of failed processes which caused the wrong events: incorrect order or requisition entry, failure to confirm patient identity, failure to follow site and procedure verification or procedure qualification processes. The authority recommended following the Universal Protocol established by the Joint Commission for preventing wrong-patient, wrong procedure errors in surgery.

“These protocols, while targeted toward preventing surgery mistakes, can be used to standardize procedures in other areas of care to ensure that patients are accurately identified and procedures correctly scheduled and performed across-the-board, not just in the operating room,” Clarke said. “An assessment tool, sample policy and teaching module of events with learning points are also available for patient safety officers to determine where their facility stands in regard to the likelihood of these events happening in their facility."