Using FMEA to Reduce the Risk of Delayed Reporting of Critical Radiological Results in Oncology: A Patient Safety...

Area of Science:

• Radiology and Oncology
• Quality Improvement Science
• Health Informatics

Background:

• Timely communication of critical radiological findings is essential in oncology for effective treatment and patient safety.
• Existing reporting protocols face challenges including manual processes, unclear escalation, and resource constraints, leading to delays.

Purpose of the Study:

• To apply Failure Mode and Effects Analysis (FMEA) to identify and mitigate high-risk failures in critical radiology result reporting within an oncology center.
• To enhance the efficiency and safety of radiology reporting processes.

Main Methods:

• A quality improvement project using a pre- and post-intervention design at a specialized oncology center.
• A multidisciplinary team utilized FMEA to score failure modes by Severity, Occurrence, and Detection, calculating Risk Priority Numbers (RPNs).
• Interventions included automated EHR alerts, standardized protocols, staff retraining, structured documentation, and improved PACS-RIS-EHR interoperability.

Main Results:

• Pre-intervention RPNs indicated significant risks (e.g., unrecognized findings RPN=320, lack of notification RPN=310).
• Post-intervention, RPNs decreased by 54-62%, with improvements in critical finding recognition (55%), notification (58%), protocol adherence (62%), and staffing (54%).
• Improvements were attributed to automation, streamlined workflows, and better system integration, confirmed by statistical analysis.

Conclusions:

• FMEA is an effective tool for identifying and mitigating critical failures in radiology reporting systems.
• Integrating technology and fostering cross-disciplinary collaboration significantly enhances reporting timeliness, compliance, and patient safety in oncology care.