Detection and Remediation of Misidentification Errors in Radiology Examination Ordering

Area of Science:

• Radiology
• Patient Safety
• Health Informatics

Background:

• Misidentification errors, such as wrong-side imaging orders, persist in radiology despite patient safety advancements.
• These errors can lead to patient harm and inaccurate electronic health records (EHR).

Purpose of the Study:

• To pilot test a quality improvement methodology using electronic trigger tools and preimaging checklists.
• To detect wrong-side misidentification errors in radiology examination ordering.
• To measure staff adherence to error remediation policies.

Main Methods:

• Retrospective comparison of two error detection methods over a 1-year period.
• Method 1: Manual review of preimaging safety checklist records.
• Method 2: Automated detection using an electronic trigger tool identifying discrepant EHR imaging orders.

Main Results:

• Combined methods detected errors in 6.5/1,000 imaging orders.
• The electronic trigger tool identified more errors than checklists alone, with high positive predictive value (88.4%).
• However, checklists detected errors missed by the trigger tool, and checklist-detected errors were resolved more often.

Conclusions:

• Electronic trigger tools significantly enhance the detection of imaging ordering misidentification errors.
• A combination of trigger tools and checklist-based methods is recommended for comprehensive patient safety.
• Further development and integration of trigger tools are needed to complement existing safety protocols.