An Ounce of Prevention

Reducing errors and eliminating wrong events in radiology takes vigilance and a culture of shared responsibility.

In 1999, the Institute of Medicine issued a report that illuminated the hazards of medical errors and generated much alarm from the concerned public. “To Err Is Human: Building a Safer Health Care System” urged the medical community to better its quality standards.

Today, radiology departments continue to rise to the challenge of enhancing the patient experience and promoting patient safety. In fact, the American Board of Radiology now requires radiologists to demonstrate their commitment to quality improvements as part of the Maintenance of Certification that is awarded every 10 years.

Robb Hoehlein, MD, medical director of radiology at East Cooper Regional Medical Center in South Carolina, described the various potential errors of which radiologists should be aware.

“There are straightforward ones like name and date discrepancies, where you read an x-ray and you think it’s on one particular patient but it’s really on another, or that the image is from today but it’s really from yesterday,” Hoehlein explained, adding that mislabeled patient identifiers can lead to adverse consequences. “If I say someone has pneumonia and that person gets treated with antibiotics, that may be inappropriate, and they could even have an allergic reaction. But more important is the person who has pneumonia, no one knows, and it doesn’t get treated appropriately.”

Other errors may involve issues with voice recognition software. Reports may be created with unnoticed omissions or inadvertent additions. For example, a pulmonary nodule may be present when the report states that one is not present. Although voice recognition errors are many times nonsensical, uncorrected mistakes reflect poorly on the radiologist. “You can be the smartest person in the world, but if you don’t correct your voice recognition mistakes, you seem foolish,” Hoehlein said. “On the flip side, if you generate very easy-to-read, straightforward reports with no errors, people will tend to have more confidence in those reports and act on them more than they would otherwise.”

Hani H. Abujudeh, MD, MBA, director of quality assurance, Department of Radiology, at Massachusetts General Hospital and associate professor of radiology at Harvard Medical School in Boston, admitted that voice recognition inaccuracies happen to every one. “But it’s something people must pay attention to,” Abujudeh said. “Our job is to read the report after we generate it.”

Three Stages of Communication

Abujudeh, who recently coauthored the text Quality and Safety in Radiology with Michael A. Bruno, MD, said errors can occur in any one of three stages of communication: the front-end, middle, or back-end—the latter of which includes voice recognition transcriptions and the generation of accurate, clear, and concise reports.

Upfront communication involves interactions between the radiologist and the referring physician. When Abujudeh was a resident, electronic methods of receiving patient information did not exist. As a result, poor information received from the referring physician would likely lead to his own poor report. Today, with the increased access to electronic medical records (EMRs), radiologists can investigate the patient history themselves if the referring physician’s report is lacking. “Availability of the EMR next to the radiologist at the time of interpretation is vitally important,” he said.

Hoehlein also pointed out that electronic innovations reduce the likelihood of errors caused by manual processes. “With PACS, I have the complete radiographic record available to me, and I don’t have to worry that the wrong patient’s film got stuck in the jacket. Having that digital record is very helpful and minimizes those kinds of errors,” he said.

In the middle stage of communication, patients have interactions with the technologist, the technologists interact with physicians, and image transfer and labeling occurs.

Sometimes, inappropriate or wrong exams may be administered. For instance, technologists may leave out an important sequence when performing a shoulder MRI or improperly plan the exam so that the angle they are obtaining for the radiologist is wrong. Although these cases are not frequent, Hoehlein emphasized that these errors happen enough that technologists must constantly be vigilant and pay close attention to their work.

Promoting Openness, Accountability

Institutional culture plays an influential role during this middle stage of communication. At Massachusetts General, Abujudeh aims to promote an atmosphere of openness and encouragement. He said he makes it a point to instruct technologists and other staff to speak up, even if they are worried about being wrong.

Hoehlein, too, believes that a friendly work environment plays a huge factor in meeting and exceeding quality standards. “I think the most important thing in preventing these sorts of things is to promote, throughout the department, that everybody is on the same team and that everyone is accountable,” he said. “Anyone should be able to raise their hand and say, ‘That’s not right.'”

Experts contend that wrong events are underreported because health care workers fear punishment for making a mistake, according to Teri Yates, CHC, chief compliance officer and director of quality management at radiology services firm Radisphere. Yates stated that her own experience validates that claim. “My experience has been that these events happen with more frequency than any of us would like to believe, and the only antidote to the problem is to bring it out into the open,” she said. “If a hospital has a just culture, where mistakes can be disclosed for learning purposes without retribution, then those mistakes are less likely to be repeated. Directors of radiology who talk regularly with their staff about the factors that lead to errors, and actively design their department’s workflow to prevent errors, will have better outcomes. Openness about the problem really makes a difference.”

Ultimately, the minimization of radiology-related errors comes down to a feeling of shared responsibility by all parties involved. “Really, it’s everybody’s responsibility: from the person who schedules the exam, to the person who checks the patient into the department, to the tech taking the images to the radiologist—each one of those people has a chance to intervene and catch a mistake,” Hoehlein said. “If you just assume it is someone else’s responsibility, you will miss opportunities to correct those errors before they ever happen or catch them early enough to make sure there is no bad outcome because of them.”

Applying the Universal Protocol

The Joint Commission’s “universal protocol,” introduced in 2003 and revised in 2008, specifically targets the reduction of wrong-site, wrong-procedure, and wrong-patient surgical procedures. Still, its principles can be applied in any medical specialty, including radiology.

As Hoehlein noted, “In carpentry, they say, ‘Measure twice, cut once.’ It’s the same thing when dealing with patients. It’s always better that you double and triple check that you are doing the correct thing and everyone is aware, instead of just assuming that you’ve got it all right.”

Yates said she advises clients to draw on the resources already available, such as the universal protocol. “Nobody has to reinvent the wheel when it comes to preventing wrong errors,” she said. “The Joint Commission has provided a protocol that really works if the participants all embrace it.” For other critical safety areas, such as contrast administration, MRI safety, and radiation dose reduction, Radisphere provides clients with its own standard policies to ensure that they adhere to appropriate standards.

Yates said her interest in the field of patient safety began back in 2001 when the tragic Michael Colombini case made headlines. The 6-year-old Colombini was killed due to an unsafe oxygen canister accidentally brought into the MRI suite. The canister became a dangerous projectile and struck the child in the head. “That case made everyone in our industry take notice that we work in a very risky business, serving as a reminder that medical errors often have very real human consequences,” Yates said. “I think about that case all the time, and put myself into the shoes of those parents when I contemplate what my responsibilities are when it comes to patient safety.”

Today’s unstable economic climate makes the subject of patient safety all the more important, according to Yates. “I think that professionals in radiology need to be extra cautious right now when it comes to patient safety,” she said. “As declining reimbursements drive the need for efficiency, it can be difficult to remain vigilant, particularly because good safety practices often involve redundancy as a safeguard. Staffing levels must be sufficient to address the needed steps, such as preprocedure time-outs, if harmful errors are to be avoided.”

Hoehlein said that at the end of the day, a smoothly run hospital sets the example for the departments within it. “It’s an institutional mind-set,” he said. “It’s infective. If it’s hospital-wide, you’re much more likely to find a radiology department that is functioning the same way.”

Concurring, Yates said good patient care yields good business. “My advice is to ensure that all members of the health care team, from senior management down through every member of the department, are aligned in their understanding that error prevention efforts have a very good return on investment,” she said.

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Elaine Sanchez-Wilson is a contributing writer for Axis Imaging News.