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Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors

Ronilda Lacson1, Laila Cochon2, Ivan Ip1

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PubMed
Summary
This summary is machine-generated.

Diagnostic imaging safety events occurred in 7% of reports, with potential harm most frequent during result communication. Multifactorial sociotechnical factors contributed to these events, necessitating further improvements in diagnostic imaging safety.

Keywords:
Patient safetydiagnostic errorsdiagnostic imagingsociotechnical factors

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Area of Science:

  • Medical Imaging
  • Patient Safety
  • Health Informatics

Background:

  • Diagnostic imaging is crucial for medical diagnosis.
  • Patient safety events in healthcare settings are a significant concern.
  • Electronic safety reporting systems are used to track adverse events.

Purpose of the Study:

  • To quantify diagnostic imaging safety events reported via an electronic system.
  • To identify specific workflow steps where these events occur.
  • To analyze contributing sociotechnical factors.

Main Methods:

  • Evaluation of 11,570 safety reports from 2015, with 854 (7%) related to diagnostic imaging.
  • Classification of events by harm score (0-4), with "potential harm" defined as scores 2-4.
  • Manual classification of reports by imaging workflow step and sociotechnical factors using the Systems Engineering Initiative for Patient Safety framework.

Main Results:

  • Imaging procedure was the most common step (54%), but potential harm was higher in result communication (OR=2.36, P=0.05).
  • Person factors contributed to 71% of reports.
  • Potential harm was significantly higher for task-related factors compared to person factors (OR=5.03, P<0.0001).

Conclusions:

  • Diagnostic imaging safety events represent 7% of all reported events.
  • Potential harm is concentrated in the imaging procedure and result communication phases.
  • Multifactorial sociotechnical elements underlie these safety events, requiring targeted interventions.