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

The purpose of this study was to describe the utility of a two-person verification system (Rad Check) in successfully decreasing wrong-patient or wrong-study errors.

In this retrospective study performed at a tertiary-care pediatric hospital, monthly radiology incident reports from January 2009 through December 2014 were reviewed for documentation of wrong-patient or wrong-study events. The date, imaging modality, nature of the event, and number of imaging studies for this time period by year were recorded and analyzed. These data were tracked before and after implementation of the two-person verification system in July 2012.

Over 72 months, 45 reported wrong-patient or wrong-study events were confirmed. The data were analyzed before and after implementation of a two-person verification system implemented in July 2012, midway through the study period. Over the first 42 months, 36 wrong-patient or wrong-study occurrences were identified, corresponding to an average of one error every 35 days, with the number of days between events ranging from 3 to 150. After implementation of the verification process, nine events were documented over 30 months, corresponding to an average of one error every 101 days, with the maximum number of days between events exceeding 410.

Wrong-patient or wrong-study events can be significantly reduced by utilizing a brief two-person verification approach. More robust documentation of these events is warranted so that individual institutions can assess the incidence of these events within their own department and develop tailored plans to prevent these errors.