Decreasing safety events and reconciliation errors in CT imaging

Imaging reconciliation errors within Picture Archiving and Communication Systems (PACS) can lead to adverse patient outcomes, unnecessary procedures, and delayed care. Historically, our institution averaged 400 safety-related events annually, including high-priority errors such as images linked to the wrong patient, incomplete image transmissions, and images stored in incorrect PACS folders. Our quality improvement (QI) team aimed to decrease high-priority reconciliation event rates in Computed Tomography (CT) from a baseline of 4.75 events per 1,000 exams to 1.9 events per 1,000 exams by June 2024.

Conducted at a large academic medical center, this continuous QI initiative deployed a bundled intervention consisting of workflow redesign and mandatory forms, technological safeguards via barcode scanners, and a cultural shift driven by data transparency and targeted coaching. Data was analyzed using statistical process control (SPC) charts.

Between July 2, 2023, and February 23, 2025, the overall rate of reconciliation events decreased to 0.1%. Potentially serious safety errors dropped to fewer than 100 per year, and the average time elapsed between reconciliation events increased by 493%. The operational burden of manual reconciliation was reduced by an estimated 150 h annually.

A sustained reduction in errors was achieved through a comprehensive system redesign. Pairing standardized workflows and mandatory documentation with high-reliability technology, data transparency, and routine feedback proved highly effective at establishing a scalable reduction in imaging errors.