Decreasing safety events and reconciliation errors in CT imaging.

Area of Science:

• Medical Imaging Informatics
• Healthcare Quality Improvement
• Patient Safety

Background:

• Imaging reconciliation errors in Picture Archiving and Communication Systems (PACS) historically caused significant patient safety events, including mislinked images and incomplete transmissions.
• The institution experienced approximately 400 safety-related events annually, necessitating targeted interventions.

Purpose of the Study:

• To decrease high-priority reconciliation event rates in Computed Tomography (CT) imaging from a baseline of 4.75 to 1.9 events per 1,000 exams.
• To enhance patient safety and reduce procedural delays caused by imaging errors.

Main Methods:

• A continuous quality improvement initiative at a major academic medical center.
• Implementation of a bundled intervention: workflow redesign, mandatory forms, barcode scanners, and data transparency with coaching.
• Analysis using statistical process control (SPC) charts.

Main Results:

• Overall reconciliation event rate decreased to 0.1% between July 2023 and February 2025.
• Potentially serious safety errors reduced to under 100 per year, with a 493% increase in the average time between events.
• Estimated reduction of 150 manual reconciliation hours annually.

Conclusions:

• A comprehensive system redesign, combining standardized workflows, mandatory documentation, reliable technology, and data feedback, effectively reduced imaging errors.
• The intervention achieved a sustained reduction in errors, proving highly effective and scalable.
• The initiative improved patient safety and operational efficiency within the PACS environment.