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[Incident Analysis in Radiography Focusing on the Experience Period of Radiological Technologist].

Daisei Iwamoto1, Yasuhiro Fukushima1, Norimasa Matsushita1

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Nihon Hoshasen Gijutsu Gakkai Zasshi
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Radiography incidents stemmed mainly from incorrect orders and retakes. While overall incident rates didn't correlate with technologist experience, patient falls and overdoses decreased with more experience, unlike detector errors and patient mismatches.

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Area of Science:

  • Medical Imaging
  • Radiography Safety
  • Healthcare Quality Improvement

Background:

  • Radiography is a cornerstone of medical diagnostics.
  • Ensuring patient safety and procedural accuracy in radiography is critical.
  • Understanding incident trends is vital for quality assurance.

Purpose of the Study:

  • To investigate the causes and trends of radiography-related incidents.
  • To analyze the relationship between incident types and the experience level of radiological technologists (RTs).

Main Methods:

  • Analysis of 384 radiography incident reports from April 2014 to March 2016.
  • Categorization of incidents by nature and correlation with RT experience periods (<3, 3-10, 11-25, >25 years).

Main Results:

  • Incorrect examination orders (50.0%) and X-ray retakes (24%) were the most frequent incidents.
  • No overall correlation between total incidents per RT and experience level.
  • 'Patient falls/injuries' and 'overdoses' were more common with less experienced RTs (<10 years).
  • 'Patient mismatch' and 'detector selection errors' were more common with more experienced RTs (>10 years).

Conclusions:

  • Radiography incident causes are diverse, with diagnostic errors being predominant.
  • While overall incident frequency is not experience-dependent, specific error types show a correlation.
  • Targeted training for less experienced RTs on patient safety and dose management is indicated.
  • Further investigation into experience-related factors for procedural and patient identification errors is warranted.