Establishing national medical imaging incident reporting systems: Issues and challenges

Journal of the American College of Radiology

Volumn 7, Issue 8, 2010, Pages 582-592

  Jones, D Neil ^a,b   Benveniste, Klee A ^c   Schultz, Timothy J ^c,d   Mandel, Catherine J ^e   Runciman, William B ^b,c  

^a FLINDERS MEDICAL CENTRE   (Australia)

^b UNIVERSITY OF SOUTH AUSTRALIA   (Australia)

^c Australian Patient Safety Foundation Inc   (Australia)

^d UNIVERSITY OF ADELAIDE   (Australia)

^e PETER MACCALLUM CANCER CENTRE   (Australia)

Author keywords

error; incident reporting; medical imaging; Patient safety; radiology

Indexed keywords

GADOLINIUM; IOFENDYLATE;

ARACHNOIDITIS; DEVICE; DIAGNOSTIC IMAGING; FOLLOW UP; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HUMAN; INCIDENT REPORT; IONIZING RADIATION; MEDICAL SOCIETY; NEPHROGENIC SYSTEMIC FIBROSIS; PATIENT SAFETY; RADIATION DOSE; REVIEW; RISK MANAGEMENT; WORLD HEALTH ORGANIZATION;

EID: 84926231542     PISSN: 15461440     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.jacr.2010.03.014     Document Type: Review

References (82)

1. L. Donaldson When will health care pass the orange-wire test? Lancet 364 2004 1567 1568
2. W. Runciman, P. Hibbert, R. Thomson, T. Van Der Schaaf, H. Sherman, and P. Lewalle Towards an international classification for patient safety: key concepts and terms Int J Qual Health Care 21 2009 18 26
3. A. Jha Summary of the evidence on patient safety: implications for research 2008 World Health Organization Geneva, Switzerland
4. B. Runciman, A. Merry, and M. Walton Safety and ethics in healthcare: a guide to getting it right 2007 Ashgate Aldershot, UK
5. World Alliance for Patient Safety World Health Organization Global priorities for research in patient safety 2008 World Health Organization Geneva, Switzerland
6. L.T. Kohn, J.M. Corrigan, and M.S. Donaldson To err is human: building a safer health system 2000 National Academy Press Washington, DC
7. Department of Health An organisation with a memory - report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer 2000 Her Majesty's Stationery Office London
8. W.B. Runciman, and J. Moller Iatrogenic injury in Australia 2001 Australian Patient Safety Foundation Adelaide
9. T.A. Brennan, L.L. Leape, and N.M. Laird, et al. Incidence of adverse events and negligence in hospitalized patients Results of the Harvard Medical Practice Study I N Engl J Med 324 1991 370 376
10. L.L. Leape, T.A. Brennan, and N. Laird, et al. The nature of adverse events in hospitalized patients Results of the Harvard Medical Practice Study II N Engl J Med 324 1991 377 384
11. E.J. Thomas, D.M. Studdert, and H.R. Burstin, et al. Incidence and types of adverse events and negligent care in Utah and Colorado Med Care 38 2000 261 271
12. R.M. Wilson, W.B. Runciman, R.W. Gibberd, B.T. Harrison, L. Newby, and J.D. Hamilton The Quality in Australian Health Care Study Med J Aust 163 1995 458 471
13. E.J. Thomas, D.M. Studdert, and W.B. Runciman, et al. A comparison of iatrogenic injury studies in Australia and the USA I: context, methods, casemix, population, patient and hospital characteristics Int J Qual Health Care 12 2000 371 378
14. W.B. Runciman, R.K. Webb, and S.C. Helps, et al. A comparison of iatrogenic injury studies in Australia and the USA II: reviewer behaviour and quality of care Int J Qual Health Care 12 2000 379 388
15. C. Vincent, G. Neale, and M. Woloshynowych Adverse events in British hospitals: preliminary retrospective record review BMJ 322 2001 517 519
16. P. Davis, R. Lay-Yee, and R. Briant Adverse events in New Zealand public hospitals: principal findings from a national survey Occasional paper no 3 2001 Ministry of Health Wellington, New Zealand
17. T. Schioler, H. Lipczak, and B.L. Pedersen, et al. Incidence of adverse events in hospitals A retrospective study of medical records [article in Danish] Ugeskr Laeger 163 2001 5370 5378
18. G.R. Baker, P.G. Norton, and V. Flintoft, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada CMAJ 170 2004 1678 1686
19. P. Michel, J. Quenon, A. Djihoud, S. Tricaud-Vialle, A. de Sarasqueta, and S. Domecq Les événements indésirables graves liés aux soins observés dans les établissements de santé: premiers résultats d'une étude nationale études et Résultats No 398 2005 Direction de la Recherche des études de L'évaluation et des Statistiques, Ministère des Solidarités, de la Santé et de la Famille Paris
20. J.M.A. Andrés, C.A. Remón, J.V. Burillo, and P.R. Lopez National Study on Hospitalisation-Related Adverse Events ENEAS 2005 2006 Ministry of Health and Consumer Affairs Madrid, Spain
21. M. Soop, U. Fryksmark, M. Köster, and B. Haglund The incidence of adverse events in Swedish hospitals: a retrospective medical record review study Int J Qual Health Care 21 2009 1 7
22. M. Zegers, M.C. de Bruijne, and C. Wagner, et al. Adverse events and potentially preventable deaths in Dutch hospitals: results of a retrospective patient record review study Qual Saf Health Care 18 2009 297 302
23. R.A. Hayward, and T.P. Hofer Estimating hospital deaths due to medical errors: preventability is in the eye of the reviewer JAMA 286 2001 415 420
24. L.B. Andrews, C. Stocking, and T. Krizek, et al. An alternative strategy for studying adverse events in medical care Lancet 349 1997 309 313
25. H. Hogan, S. Olsen, and S. Scobie, et al. What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management? Qual Saf Health Care 17 2008 209 215
26. J.B. Cooper, R.S. Newbower, C.D. Long, and B. McPeek Preventable anesthesia mishaps: a study of human factors Anesthesiology 49 1978 399 406
27. J. Williamson Critical incident reporting in anaesthesia Anaesth Intensive Care 16 1988 101 103
28. J.A. Williamson, and P. Mackay Incident reporting Med J Aust 155 1991 340 344
29. W.B. Runciman, A. Sellen, and R.K. Webb, et al. The Australian Incident Monitoring Study Errors, incidents and accidents in anaesthetic practice Anaesth Intensive Care 21 1993 506 519
30. J.B. Battles, and D.P. Stevens Adverse event reporting systems and safer healthcare Qual Saf Health Care 18 2009 2
31. G.S. Meyer, J. Battles, J.C. Hart, and N. Tang The US Agency for Healthcare Research and Quality's activities in patient safety research Int J Qual Health Care 15 suppl 2003 i25 i30
32. World Alliance for Patient Safety WHO draft guidelines for adverse event reporting and learning systems 2005 World Health Organization Geneva, Switzerland
33. R.I. Cook, D.D. Woods, and C. Miller A tale of two stories: contrasting views of patient safety Report from a Workshop on Assembling the Scientific Basis of Patient Safety 1998 National Patient Safety Foundation at the AMA Chicago, Ill
34. J. Benn, M. Koutantji, and L. Wallace, et al. Feedback from incident reporting: information and action to improve patient safety Qual Saf Health Care 18 2009 11 21
35. J.P. Bagian Patient safety: lessons learned Pediatr Radiol 36 2006 287 290
36. W.B. Runciman, J.A. Williamson, A. Deakin, K.A. Benveniste, K. Bannon, and P.D. Hibbert An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification Qual Saf Health Care 15 suppl 2006 i82 i90
37. D. Jones, and W.B. Runciman Principles of incident reporting P. Croskerry, K.S. Cosby, S.M. Schenkel, R.L. Wears, Patient safety in emergency medicine 2008 Lippincott Williams & Wilkins Philadelphia 70 74
38. M.J. Kingston, S.M. Evans, B.J. Smith, and J.G. Berry Attitudes of doctors and nurses towards incident reporting: a qualitative analysis Med J Aust 181 2004 36 39
39. J. Braithwaite, M. Westbrook, and J. Travaglia Attitudes toward the large-scale implementation of an incident reporting system Int J Qual Health Care 20 2008 184 191
40. US Food and Drug Administration Manufacturer and User Facility Device Experience Database (MAUDE) http://www.fda.gov/MedicalDevices/ DeviceRegulationandGuidance/PostmarketRequirements/ReportingAdverseEvents/ ucm127891.htm Accessed December 18, 2009
41. Australian Government Department of Health and Ageing Therapeutic Goods Administration http://www.tga.gov.au Accessed December 18, 2009
42. Department of Health Medicines and Healthcare Products Advisory Agency http://www.mhra.gov.uk/index.htm Accessed December 18, 2009
43. J.L. White Adverse event reporting and learning systems: a review of the literature 2007 Canadian Patient Safety Institute Edmonton
44. P. Aspden, J.M. Corrigan, J. Wolcott, and S.M. Erickson Institute of Medicine Committee on Data Standards Patient safety: achieving a new standard for care 2004 National Academies Press Washington, DC
45. O. Levtzion-Korach, H. Alcalai, and E.J. Orav, et al. Evaluation of the contributions of an electronic web-based reporting system: enabling action J Patient Saf 5 2009 9 15
46. D.O. Farley, A. Haviland, and S. Champagne, et al. Adverse-event- reporting practices by US hospitals: results of a national survey Qual Saf Health Care 17 2008 416 423
47. K.G. Shojania The frustrating case of incident-reporting systems Qual Saf Health Care 17 2008 400 402
48. S.M. Evans, J.G. Berry, and B.J. Smith, et al. Attitudes and barriers to incident reporting: a collaborative hospital study Qual Saf Health Care 15 2006 39 43
49. K. Mankad, E.T. Hoey, J.B. Jones, P. Tirukonda, and J.T. Smith Radiology errors: are we learning from our mistakes? Clin Radiol 64 2009 988 993
50. J.J. Waring Beyond blame: cultural barriers to medical incident reporting Soc Sci Med 60 2005 1927 1935
51. A.F. Smith, and R.P. Mahajan National critical incident reporting: improving patient safety Br J Anaesth 103 2009 623 625
52. W.B. Runciman, A.F. Merry, and F. Tito Error, blame, and the law in health care - an antipodean perspective Ann Intern Med 138 2003 974 979
53. M. Bismark, and R. Paterson No-fault compensation in New Zealand: harmonizing injury compensation, provider accountability, and patient safety Health Aff (Millwood) 25 2006 278 283
54. U. Hellbacher, C. Espersson, and H. Johansson Patient injury compensation for healthcare-related injuries http://www.patientforsakring.se/pdf/ patientskadeersattning-english.pdf Accessed December 15, 2009
55. J.M. Gilmour Patient safety, medical safety and tort law: an international comparison. Final report http://osgoode.yorku.ca/osgmedia.nsf/0/ 094676DE3FAD06A5852572330059253C/$FILE/FinalReport-Full.pdf Accessed December 15, 2009
56. Scottish Government No-fault compensation review group http://www.scotland.gov.uk/Topics/Health/NHS-Scotland/No-faultCompensation Accessed December 15, 2009
57. Department of Health and Children, Ireland Advisory group on no fault compensation for brain-damaged infants http://www.dohc.ie/working-groups/ Current/cbdi/ Accessed December 15, 2009
58. S.F. Halpin Medico-legal claims against English radiologists: 1995-2006 Br J Radiol 82 2009 982 988
59. Australian and New Zealand College of Radiologists Welcome to the Radiology Events Register (RaER) http://www.raer.org Accessed February 15, 2010
60. Australian Council for Safety and Quality in Health Care National report on qualified privilege http://www.safetyandquality.gov.au/internet/safety/ publishing.nsf/Content/F22384CCE74A9F01CA257483000D845E/$File/qual-priv1. pdf Accessed December 15, 2009
61. Commonwealth of Australia Health Insurance Act 1973. Part VC: quality assurance confidentiality http://www.austlii.edu.au/au/legis/cth/consol-act/ hia1973164/ Accessed December 10, 2009
62. Commonwealth of Australia Health Insurance Act 1973. Declaration of quality assurance activity under section 124X. Schedule: QAA No 1/2008: RCPA Quality Assurance Programs Pty Limited. Key Incident Monitoring and Management System. Federal Register of Legislative Instruments F2009C00201; 2009 http://www.scaleplus.law.gov.au/ComLaw/legislation/ legislativeinstrumentcompilation1.nsf/0/8B99C0A5F9AC53C5CA2575B70021E8A2/ $file/0272009COMP3.pdf Accessed December 10, 2009
63. Patient Safety and Quality Improvement Act of 2005 Pub L No 109-41, 2005 http://www.pso.ahrq.gov/statute/pl109-41.pdf Accessed December 10, 2009
64. Agency for Healthcare Research and Quality Patient Safety Organization Privacy Protection Center https://www.psoppc.org/web/patientsafety Accessed December 10, 2009
65. S. Smith How the dye was cast: shedding light on a dark industry http://www.arachnoiditis.info/content/pantopaque/sarahs-pantopaque.doc Accessed December 15, 2009
66. J. George Adhesive arachnoiditis http://parlinfo.aph.gov.au/parlInfo/ genpdf/chamber/hansardr/2002-09-16/0101/hansard-frag.pdf; fileType%3Dapplication%2Fpdf Accessed December 15, 2009
67. H.S. Thomsen Nephrogenic systemic fibrosis: history and epidemiology Radiol Clin North Am 47 2009 827 831
68. US Food and Drug Administration MedWatch: the FDA Safety Information and Adverse Event Reporting Program http://www.fda.gov/safety/MedWatch/default.htm Accessed December 15, 2009
69. GE Healthcare Omniscan safety review advisory meeting briefing document Version 1.0 http://www.fda.gov/downloads/AdvisoryCommittees/ CommitteesMeetingMaterials/Drugs/DrugSafetyandRiskManagementAdvisoryCommittee/ UCM192009.pdf Accessed December 15, 2009
70. R. Fazel, H.M. Krumholz, and Y. Wang, et al. Exposure to low-dose ionizing radiation from medical imaging procedures N Engl J Med 361 2009 849 857
71. US Food and Drug Administration Safety investigation of CT brain perfusion scans: update 12/8/2009 http://www.fda.gov/MedicalDevices/Safety/ AlertsandNotices/ucm185898.htm Accessed December 15, 2009
72. Radiation exposure lawsuit filed over CT scans at LA hospital http://wwwaboutlawsuits.com/radiation-exposure-lawsuit-filed-over-ct-scans-at- la-hospital-6558/ Accessed December 15, 2009
73. US Food and Drug Administration MAUDE adverse event report: picture archiving communication system http://www.accessdata.fda.gov/scripts/cdrh/ cfdocs/cfMAUDE/Detail.CFM?MDRFOI--ID=727286 Accessed December 18, 2009
74. T. Collins 290 patient safety incidents reported under NPfIT scheme http://www.computerweekly.com/blogs/tony-collins/2008/04/290-patient-safety- incidents-r.html Accessed December 15, 2009
75. E.M. Campbell, D.F. Sittig, J.S. Ash, K.P. Guappone, and R.H. Dykstra Types of unintended consequences related to computerized provider order entry J Am Med Inform Assoc 13 2006 547 556
76. H.A. Abella Canadian province probes new radiology reading messDiagn Imaging http://www.diagnosticimaging.com/display/article/113619/1482963?verify=0 Accessed December 15, 2009
77. Health Service Executive North East Radiology Look-Back Review Steering Group Review of chest x-rays and CT scans reported by a locum consultant radiologist at Louth Meath Hospitals from August 2006 to August 2007 http://www.hse.ie/eng/services/Publications/services/Hospitals/ NERadiologyReview.pdf
78. C.J. Garvey, and S. Connolly Radiology reporting - where does the radiologist's duty end? Lancet 367 2006 443 445
79. L. Berlin Communicating findings of radiologic examinations: whither goest the radiologist's duty? AJR Am J Roentgenol 178 2002 809 815
80. Patient safety, supported by the NPSA and the Healthcare Commission http://wwwhsj.co.uk/patient-safety-supported-by-the-npsa-and-the-healthcare- commission/1901093.article Accessed December 15, 2009
81. J.L. Taylor Medical negligence Bull Hong Kong Med Assoc 27 1975 109 113
82. National Patient Safety Agency Safer practice notice: early identification of failure to act on radiological imaging reports. NPSA/2007/16 http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59817 Accessed December 15, 2009