ARRS 2022 Abstracts


1607. Radiology Specific Patient Safety Event Reporting System Version 2.0 in a Multisite Academic Institution
Authors * Denotes Presenting Author
  1. Daniel Dickman *; Mayo Clinic - Arizona
  2. Richard Sharpe Jr; Mayo Clinic - Arizona
  3. Daniel Bor; Medical College of Wisconsin
  4. Lisa Ponce; Mayo Clinic - Arizona
  5. Cathy Hannafin; Mayo Clinic - Arizona
  6. Jonathan Flug; Mayo Clinic - Arizona
Clinical incident reporting tools log potential and actual safety events and trend events over time to identify improvement opportunities. A radiology-specific event reporting system was deployed in 2004 at our large multisite academic medical center. The reporting system categorized events into several general event categories, was widely used, and allowed us to trend data and implement some improvements. After 15 years of use, we identified opportunities to improve the tool, as some event categories were insufficiently precise, and we developed a need for additional subcategories. We recently implemented a revised radiology specific event reporting system to more effectively support logging of safety events, enable enhanced trending across multiple domains, and better meet the current needs of patients, our department, and stakeholders. The purpose of this project is to describe the recently revised clinical incident reporting system and the trends observed two years after its implementation.

Materials and Methods:
The revised web-based HIPAA-compliant radiology-specific event reporting system was created by a multidisciplinary team of radiology stakeholders. Events were categorized into one of 10 general event categories (exam/procedure, fall, IV/vascular access, lab/specimen, medication/isotope, MRI safety, safety/security, patient care delay, patient harm/risk, and patient ID). The revised tool includes new predefined subcategories (specific event types, contributing factors, and immediate action). Submissions from June 5, 2019 to August 10, 2021 were extracted and analyzed.

10,256 events were logged during the study period. The most frequently general event types included: exam/procedure/imaging (3087, 30.1%), patient care delay (2733, 26.7%), IV/vascular access (1554, 15.1%), and patient harm/risk (1120, 10.9%). The most frequent specific event types included: delay in performing exam (2372/10,305, 23.0%), exam/procedure ordered incorrectly (1234, 12.0%), contrast extravasation (1076, 10.4%), and exam performed incorrectly (443, 4.3%). The most frequent contributing factors included: poor venous access (619, 6.0%), incorrect exam/procedure order (496, 4.8%), incorrect order side/site (365, 3.5%), communication/handoff (352, 3.4%). The most frequent immediate action included: order corrected (723, 7.1%), reported to supervisor (723, 4.9%), no action required (470, 4.6%), schedule adjusted / completed same day (370, 3.6%).

The revised radiology-specific safety event reporting tool was widely used to regularly identify potential and actual safety events. By updating general event types and creating more specific subcategory categorized data fields, we enabled more detailed trending across multiple domains to support targeted departmental improvement efforts.