Time-Out: It's Radiology's Turn--Incidence of Wrong-Patient or Wrong-Study Errors

Area of Science:

• Radiology
• Patient Safety
• Healthcare Quality Improvement

Background:

• Wrong-patient or wrong-study events are critical errors in medical imaging.
• Accurate patient and study identification is paramount for safe and effective radiological procedures.

Purpose of the Study:

• To evaluate the effectiveness of a two-person verification system, named Rad Check, in reducing wrong-patient or wrong-study errors.
• To quantify the impact of the Rad Check system on error rates in a pediatric hospital setting.

Main Methods:

• Retrospective review of radiology incident reports from January 2009 to December 2014 at a tertiary-care pediatric hospital.
• Analysis of wrong-patient or wrong-study events before and after the implementation of the Rad Check system in July 2012.

Main Results:

• A total of 45 wrong-patient or wrong-study events were confirmed over 72 months.
• Before Rad Check implementation, 36 events occurred in 42 months (average one error every 35 days).
• After Rad Check implementation, 9 events occurred in 30 months (average one error every 101 days), indicating a significant reduction.

Conclusions:

• A brief two-person verification approach, such as Rad Check, can substantially decrease wrong-patient or wrong-study events.
• Enhanced documentation of these errors is recommended for institutions to monitor incidence and develop targeted prevention strategies.