A system-based analysis of radiology patient safety events (PSEs) has revealed recurring harm patterns and vulnerable populations, researchers have reported.
The findings highlight "opportunities for improvement and emphasize the need for standardized classification and harm scales to support broader system-level quality efforts across institutions," wrote a team led by Steven Baccei, MD, of the University of Massachusetts Memorial Health and the University of Massachusetts Chan Medical School, both in Worcester. The group's results were published April 8 in Current Problems in Diagnostic Radiology.
Radiology PSEs are often considered as isolated incidents, with documentation on them archived and limited system-level review. As a result, "patterns and vulnerabilities remain hidden, limiting the potential for meaningful quality improvement," Baccei and colleagues noted.
"As with other adverse events in healthcare, PSEs often arise not from a single individual mistake, but from underlying system flaws and interacting latent factors that become apparent through root cause analysis," they wrote.
The investigators conducted an analysis of 25 months of safety event reports from between June 2017 and June 2019 to assess the value of a system-based approach for identifying patterns of harm, vulnerable populations, and areas for improvement in radiology. They defined PSEs according to guidelines from the Agency for Healthcare Research and Quality (AHRQ) and categorized them based on narrative descriptions (under this framework, PSEs were defined as "incidents," "near misses," and "unsafe conditions"); those attributed to radiology were evaluated by type, patient demographics, radiologist involvement, and harm severity.
The analysis included 22,285 total safety events, of which 719 (3.2%) were radiology-related and 591 (2.7%) involved patients. The mean age of patients with PSEs was 55 years.
The group reported the most common PSE categories were medication and contrast administration, communication and coordination failures, and patient handling and physical safety.
Radiology-related patient safety event categories | |
Type of event | Percentage |
| Medication and contrast administration | 23% |
| Communication and coordination failures | 21.5% |
| Patient handling and physical safety | 19.3% |
| Procedural | 14.7% |
| Equipment and environmental factors | 9.1% |
| Behavioral and human factors | 6.6% |
| Diagnostic accuracy and interpretation | 5.8% |
The investigators also found the following:
- Children (7.1% versus 3.9% adults) and older adults (42.3% versus 33.5% adults) were disproportionately represented.
- Radiologists were involved in 9.3% of events, primarily in diagnostic and procedural categories.
- Most PSEs (71.6%) resulted in emotional distress, with medication and contrast administration carrying the highest relative risk of patient harm.
The study shows that "system-level analysis of PSEs can identify recurring vulnerabilities within radiology workflows and inform targeted improvements to enhance patient safety, according to the group.
"Our findings also highlight several opportunities to improve risk mitigation strategies, including enhancing staff training on specific protocols such as patient identification, contrast administration, and communication during handoffs," it concluded. "However, to promote consistency and broader adoption across institutions, collaborative efforts are needed to develop a consensus-based standardized classification system and harm scale tailored to radiology."
Access the full study here.
