Radiology is a high-tech environment where human error can occur in many stages of the examination process. Several surveys indicate that radiologists consider patient safety to be a high priority.
The aim is to keep radiation doses as low as reasonably achievable without jeopardizing diagnostic information. To do this, radiologists must be gatekeepers as well as imaging experts.
Preventive Measures
A variety of preventive measures can be taken to cut down on radiology errors and resulting patient harm. These range from simple to complex, but they all aim to improve radiologists’ abilities and the systems that support them in order to reduce human error.
For example, it is important that radiographers and radiologists are able to access all the information they need about a patient at any time. This includes data in the hospital information system, the RIS and the PACS. This allows them to see previous images, perform the appropriate procedure and monitor patient progress. In addition, a radiologist should be able to access all information relating to the case in which they are currently working, including results of other investigations and clinical notes.
Errors can also be prevented by ensuring that radiology equipment is not contaminated with microorganisms. This is particularly important when radiologists need to change equipment for different procedures, as a failure to do so can lead to cross-contamination of the new equipment and subsequent exposure of patients to potentially harmful bacteria and viruses. Chin supports, chest racks, fluoroscopy equipment and X-ray tubes are all potential sources of contamination for which a thorough cleaning and disinfection procedure is required.
The radiologists themselves can also be responsible for preventive measures, including promoting a culture of continuous attention to quality improvement. This can be done through regular departmental meetings or through other quality assurance initiatives such as a monthly incident report conference. In this meeting, division technical managers, senior radiologists and fellows discuss incidents that have occurred in their areas of expertise. This provides a forum to examine the causes of such events and explore possible ways in which they can be avoided moving forward.
Psychological interventions can also help to cut down on diagnostic errors. A study published in Academic Radiology found that the majority of errors were due to a radiologist’s failure to recognise the presence of a lesion, and that this was often caused by fatigue or cognitive overload. The authors suggest that psychological strategies could cut down on these errors by helping radiologists to realise how they can be limited by their own intuition.
Detection
Radiologists and radiographers should always be aware of their surroundings and check to make sure that they are using the correct patient identification numbers. This is essential to avoid unnecessary radiation exposure and ensure that the right body part is being examined. Similarly, the patient’s name should be written on the chart or displayed on the monitor during the examination and the equipment should be switched off after every scan. The radiologist should also verify that the corresponding medical information in the hospital information system, RIS, or picture archiving and communication systems (PACS) matches the patient being examined. This is the responsibility of all healthcare professionals and helps to avoid unintentional and unexplained overexposures, which are often referred to as ‘dose incidents’.
In the radiology department, patients from the ambulatory care and emergency departments mix with inpatients. This results in a constant flow of patients who can contaminate surfaces and the air with infectious pathogens. Therefore, it is important to perform thorough surface cleaning between each patient and that the radiographers use more rigorous sterilization protocols than those required for outpatient procedures.
All radiologists and radiographers should have access to the clinical data relevant to their work. However, this may require navigating multiple computer systems in order to view images and other information. This can lead to visual and cognitive fatigue, which in turn can affect lesion detection and decision-making. It is therefore crucial to incorporate strategies to promote and sustain productivity.
It is important for all healthcare providers to communicate with each other, whether it be between different departments or within the same department. In the case of radiology, this requires effective communication between radiographers, technologists, nurses, medical physicists, administrators, and schedulers. This will enable everyone to identify and resolve issues in a timely manner, and it will also help to improve quality and safety.
The radiologist has a moral, professional and legal responsibility to protect patients’ safety. This can only be achieved if everyone works together to foster a culture of patient safety. However, it is important to remember that even with the best of intentions, errors will occasionally occur.
Response
Radiologists have a moral, professional, and legal responsibility to protect the safety of patients receiving imaging studies with ionizing radiation. But it takes teamwork to meet that critical mandate, according to a presentation at ECR 2017. Thus, it is also important to have a reliable radiology information system provider.
Radiologists must work with other health care professionals (HCPs) to create a culture of patient safety that ensures a safe workplace for all. The HCPs may include radiologists, radiographers, nurses, medical physicists, equipment manufacturers, and scheduling experts, among others.
All HCPs should be aware of the risks and benefits associated with an imaging examination. A comprehensive communication plan needs to be implemented and regularly updated. The referring physician can play a key role in this by writing relevant referrals.
The radiology department must also ensure that its personnel can respond to potential emergency situations. For example, on-site and remote radiologist support during disasters has been suggested as a way to reduce hospital transfers and help prevent radiation exposure, injury, or even death. The ECR has published three European training curricula for radiology, with specific emphasis on patient safety-related content.
Proactive patient safety work should involve ongoing dialogue between all the actors involved in the periradiologic process. This includes the referring clinician, the imaging department staff, and the patient. This can be done through formal meetings, the use of checklists, and establishing a system of feedback.
Another important aspect of this proactive approach is to establish a culture of continuous improvement in the radiology department. This requires a strong commitment to excellence and a clear definition of quality that encompasses both patient safety and efficiency.
Achieving quality requires a high level of competence, which is only possible with well-trained staff. This is a complex task that involves both educating new staff members and ensuring that experienced staff continue to perform at an optimal level.
The radiologist’s job can be stressful, and stress is associated with poor performance. To maintain good work performance, it is essential to provide adequate time off for rest and relaxation, a reasonable pace of work, and fair treatment of all staff members. It is also important to establish effective communication channels with other departments and outside stakeholders. This is crucial in the prevention of errors.
Follow-Up
The radiologist’s knowledge of how to best investigate an abnormality and his or her ability to judge whether studies requested are appropriate for the clinical question in hand are key factors to prevent patient harm. However, if radiologists are not well-trained in how to choose the wisest and safest methods of investigation, they may follow pathways that fit with their own interests or knowledge, or simply with a preconception (“if you have a hammer, everything looks like a nail”), rather than with what is most likely to help the patient.
Another important factor in ensuring patient safety is the quality of communication between radiologists and other healthcare professionals, including referring physicians. The risk for errors increases when critical information is not properly communicated or recorded. In addition, radiology technologists need to effectively interact with patients of all ages, explaining procedures and ensuring they understand them. Because of staffing and workload pressures, this can be challenging.
It is also critical to ensure that all personnel working in the department are familiar with and use the department’s policies, protocols, and guidelines for detecting and reporting errors. This is essential for the effective management of incidents and to promote a positive safety culture in the department. A radiology department’s safety culture should be continuously assessed and improved, with the radiographers’ satisfaction with this aspect of the service being one of the most important elements to measure.
While the radiologists surveyed expressed satisfaction with their workplace’s overall safety culture, they highlighted weaknesses in the areas of “Staffing”, “Frequency of error reporting”, and “Organisational learning – continuous improvement”. In addition, they felt that their executive management was not sufficiently supportive of a positive patient safety culture.
For all radiologists, medical physicists, and radiographers, preventing patient harm should not only be a moral and professional obligation, but also a legal one. Foley noted that a number of recent changes to the European radiation protection regulations, including the new Basic Safety Standards via Directive 2013/59/Euratom, have added to the responsibilities of individuals involved in radiology. These include the responsibilities for justification, optimization, and limiting radiation exposure to patients.
