As many as 300,000 prior imaging studies at hospitals in southern Australia were mismatched to incorrect body parts during a software migration to a new enterprise imaging PACS, according to an article published June 19 in the Advertiser.
The coding errors -- including wrists being listed as feet, brains identified as chests, and breasts called heads -- occurred during SA Health's transition to its new enterprise image management system, according to the article. The software's programs had been updated to align with new codes in SA Health's new electronic patient record software. However, these new codes had triggered "an avalanche" of mismatched images when prior imaging studies were uploaded to the new image management system, the Advertiser reported.
Errors occurred at Royal Adelaide Hospital, Women's and Children's Hospital, Lyell McEwin Hospital, and Queen Elizabeth Hospital. The exception was Flinders Medical Centre, which identified the problem last year and notified officials; this led to a software update that ensured accurate body-part matching, according to the article.
An inquiry by SA Medical Imaging sought urgent feedback from staff regarding "negative patient outcomes," according to the Advertiser, which obtained a copy of the internal memo.
SA Health officials noted that potential solutions include the low-cost option of educating staff to always double-check for labeling errors, in the hope that the issue would be "very low/negligible risk within five years," according to the article. More expensive options under consideration include rematching the historical images with the corrected codes, or seeing if computer experts can find a "flagging" system that would alert doctors to known types of mismatches.
