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Berkhout C, Berbra O, Favre J, Collins C, Calafiore M, Peremans L, Van Royen P. Defining and evaluating the Hawthorne effect in primary care, a systematic review and meta-analysis. Front Med (Lausanne) 2022; 9:1033486. [PMID: 36425097 PMCID: PMC9679018 DOI: 10.3389/fmed.2022.1033486] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/18/2022] [Indexed: 10/31/2023] Open
Abstract
In 2015, we conducted a randomized controlled trial (RCT) in primary care to evaluate if posters and pamphlets dispensed in general practice waiting rooms enhanced vaccination uptake for seasonal influenza. Unexpectedly, vaccination uptake rose in both arms of the RCT whereas public health data indicated a decrease. We wondered if the design of the trial had led to a Hawthorne effect (HE). Searching the literature, we noticed that the definition of the HE was unclear if stated. Our objectives were to refine a definition of the HE for primary care, to evaluate its size, and to draw consequences for primary care research. We designed a Preferred Reporting Items for Systematic reviews and Meta-Analyses review and meta-analysis between January 2012 and March 2022. We included original reports defining the HE and reports measuring it without setting limitations. Definitions of the HE were collected and summarized. Main published outcomes were extracted and measures were analyzed to evaluate odds ratios (ORs) in primary care. The search led to 180 records, reduced on review to 74 for definition and 15 for quantification. Our definition of HE is "an aware or unconscious complex behavior change in a study environment, related to the complex interaction of four biases affecting the study subjects and investigators: selection bias, commitment and congruence bias, conformity and social desirability bias and observation and measurement bias." Its size varies in time and depends on the education and professional position of the investigators and subjects, the study environment, and the outcome. There are overlap areas between the HE, placebo effect, and regression to the mean. In binary outcomes, the overall OR of the HE computed in primary care was 1.41 (95% CI: [1.13; 1.75]; I 2 = 97%), but the significance of the HE disappears in well-designed studies. We conclude that the HE results from a complex system of interacting phenomena and appears to some degree in all experimental research, but its size can considerably be reduced by refining study designs.
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Affiliation(s)
- Christophe Berkhout
- Department of General Practice/Family Medicine, Université de Lille, Lille, France
- Department of Family Medicine and Population Health, Universiteit Antwerpen, Antwerp, Belgium
| | - Ornella Berbra
- Department of General Practice/Family Medicine, Université de Lille, Lille, France
| | - Jonathan Favre
- Department of General Practice/Family Medicine, Université de Lille, Lille, France
| | | | - Matthieu Calafiore
- Department of General Practice/Family Medicine, Université de Lille, Lille, France
- ULR 2694 METRICS, Université de Lille, Lille, France
| | - Lieve Peremans
- Department of Family Medicine and Population Health, Universiteit Antwerpen, Antwerp, Belgium
- Department of Nursing and Midwifery, Universiteit Antwerpen, Antwerp, Belgium
| | - Paul Van Royen
- Department of Family Medicine and Population Health, Universiteit Antwerpen, Antwerp, Belgium
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Jabin MSR, Schultz T, Mandel C, Bessen T, Hibbert P, Wiles L, Runciman W. A Mixed-Methods Systematic Review of the Effectiveness and Experiences of Quality Improvement Interventions in Radiology. J Patient Saf 2022; 18:e97-e107. [PMID: 32433438 DOI: 10.1097/pts.0000000000000709] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients. METHODS Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design. RESULTS Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication. CONCLUSIONS The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.
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Affiliation(s)
| | - Tim Schultz
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia
| | - Catherine Mandel
- Swinburne Neuroimaging, Swinburne University of Technology, Melbourne, Victoria
| | - Taryn Bessen
- Royal Adelaide Hospital, South Australian Medical Imaging, Adelaide, South Australia
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales
| | - Louise Wiles
- From the Australian Centre for Precision Health, University of South Australia
| | - William Runciman
- Australian Patient Safety Foundation, University of South Australia, Adelaide, South Australia, Australia
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3
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Osborne SR, Cockburn T, Davis J. Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981-2018. J Multidiscip Healthc 2021; 14:2397-2413. [PMID: 34511923 PMCID: PMC8421039 DOI: 10.2147/jmdh.s316166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/13/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law. Design Setting and Participants We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We used a modified four-step process to conduct a systematic review of legal doctrine, combined with a narrative synthesis approach to bring the information together for understanding. We searched LexisNexis, AustLII, Coroner Court websites, Australian Health Practitioner Regulation Agency Tribunal Decisions and Panel Hearings, Civil and Administrative Tribunal summaries, and other online sources for publicly available civil cases, medical disciplinary cases, coronial cases, and criminal cases across all Australian jurisdictions. Results Ten cases met the inclusion criteria, including one coronial case, three civil appeal cases, and six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the human costs of retained surgical items, that is, the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment. Conclusion While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.
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Affiliation(s)
- Sonya R Osborne
- School of Nursing and Midwifery, Faculty of Health, Engineering and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Queensland, Australia
| | - Tina Cockburn
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Juliet Davis
- Griffith Criminology Institute, Griffith University, Mt Gravatt, Queensland, Australia
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Abdul Rahman K, Ahmad SA, Che Soh A, Ashari A, Wada C, Gopalai AA. The Association of Falls with Instability: An Analysis of Perceptions and Expectations toward the Use of Fall Detection Devices Among Older Adults in Malaysia. Front Public Health 2021; 9:612538. [PMID: 33681130 PMCID: PMC7928312 DOI: 10.3389/fpubh.2021.612538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/18/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Falls are a significant incident among older adults affecting one in every three individuals aged 65 and over. Fall risk increases with age and other factors, namely instability. Recent studies on the use of fall detection devices in the Malaysian community are scarce, despite the necessity to use them. Therefore, this study aimed to investigate the association between the prevalence of falls with instability. This study also presents a survey that explores older adults' perceptions and expectations toward fall detection devices. Methods: A cross-sectional survey was conducted involving 336 community-dwelling older adults aged 50 years and older; based on randomly selected participants. Data were analyzed using quantitative descriptive analysis. Chi-square test was conducted to investigate the associations between self-reported falls with instability, demographic and walking characteristics. Additionally, older adults' perceptions and expectations concerning the use of fall detection devices in their daily lives were explored. Results: The prevalence of falls was 28.9%, where one-quarter of older adults fell at least once in the past 6 months. Participants aged 70 years and older have a higher fall percentage than other groups. The prevalence of falls was significantly associated with instability, age, and walking characteristics. Around 70% of the participants reported having instability issues, of which over half of them fell at least once within 6 months. Almost 65% of the participants have a definite interest in using a fall detection device. Survey results revealed that the most expected features for a fall detection device include: user-friendly, followed by affordably priced, and accurate. Conclusions: The prevalence of falls in community-dwelling older adults is significantly associated with instability. Positive perceptions and informative expectations will be used to develop an enhanced fall detection incorporating balance monitoring system. Our findings demonstrate the need to extend the fall detection device features aiming for fall prevention intervention.
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Affiliation(s)
- Kawthar Abdul Rahman
- Programme of Gerontechnology, Malaysian Research Institute on Ageing, Universiti Putra Malaysia, Serdang, Malaysia
| | - Siti Anom Ahmad
- Programme of Gerontechnology, Malaysian Research Institute on Ageing, Universiti Putra Malaysia, Serdang, Malaysia.,Department of Electrical and Electronic Engineering, Faculty of Engineering, Universiti Putra Malaysia, Serdang, Malaysia
| | - Azura Che Soh
- Department of Electrical and Electronic Engineering, Faculty of Engineering, Universiti Putra Malaysia, Serdang, Malaysia
| | - Asmidawati Ashari
- Department of Human Development and Family Studies, Faculty of Human Ecology, Universiti Putra Malaysia, Serdang, Malaysia
| | - Chikamune Wada
- Graduate School of Life Science and System Engineering, Kyushu Institute of Technology, Kitakyushu, Japan
| | - Alpha Agape Gopalai
- Advanced Engineering Platform, School of Engineering, Monash University Malaysia, Subang Jaya, Malaysia
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Radecki B, Keen A, Miller J, McClure JK, Kara A. Innovating Fall Safety: Engaging Patients as Experts. J Nurs Care Qual 2021; 35:220-226. [PMID: 32433144 DOI: 10.1097/ncq.0000000000000447] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Injury falls are common, with nearly a million hospitalized patients falling annually. Fall risk identification and prevention are largely clinician-centric, lacking patient input. LOCAL PROBLEM Our fall rates were below the national mean; however, patients who fell and sustained injury were at or above the mean. We lacked processes that engaged patients as safety collaborators. METHODS This was a quality improvement study examining the effect of a collaborative fall intervention on (1) patient knowledge in action and (2) incidence of falls. INTERVENTION The patient fall assessment tool was implemented to facilitate collaborative safety conversations. RESULTS We achieved a statistically significant improvement (P = .0007) in the patient's participation in the development of the safety plan, with a 25% reduction in total falls and a 67% reduction in injury falls. CONCLUSIONS The patient fall assessment tool may be a successful strategy to engage patients in the development of their safety plan and positively affect safety partnerships.
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Affiliation(s)
- Bethany Radecki
- Quality and Patient Safety, Indiana University Health Academic Health Center, Indianapolis (Mss Radecki, Keen, and Miller and Dr Kara); and Riverview Health-Westfield Hospital, Westfield, Indiana (Ms McClure)
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Patient Falls in Mohs Surgery Practices: A Survey of American College of Mohs Surgery Members. Dermatol Surg 2019; 45:1102-1104. [PMID: 31344008 DOI: 10.1097/dss.0000000000001711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Flug JA, Ponce LM, Osborn HH, Jokerst CE. Never Events in Radiology and Strategies to Reduce Preventable Serious Adverse Events. Radiographics 2018; 38:1823-1832. [DOI: 10.1148/rg.2018180036] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Jonathan A. Flug
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Lisa M. Ponce
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Howard H. Osborn
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Clinton E. Jokerst
- From the Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ 85054
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Jaimes C, Murcia DJ, Miguel K, DeFuria C, Sagar P, Gee MS. Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports. Pediatr Radiol 2018; 48:66-73. [PMID: 29051964 DOI: 10.1007/s00247-017-3989-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 07/14/2017] [Accepted: 09/12/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population. OBJECTIVE To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors. MATERIALS AND METHODS In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0-18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects. RESULTS A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%). CONCLUSION The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention.
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Affiliation(s)
- Camilo Jaimes
- Division of Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Diana J Murcia
- Division of Abdominal Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Karen Miguel
- Quality and Safety Office, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Cathryn DeFuria
- Quality and Safety Office, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Pallavi Sagar
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital for Children, Harvard Medical School, 55 Fruit St., Ellison 237, Boston, MA, 02114, USA
| | - Michael S Gee
- Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital for Children, Harvard Medical School, 55 Fruit St., Ellison 237, Boston, MA, 02114, USA.
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Harper KJ, Barton AD, Bharat C, Petta AC, Edwards DG, Arendts G, Celenza A. Risk Assessment and the Impact of Point of Contact Intervention Following Emergency Department Presentation with a Fall. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2017. [DOI: 10.1080/02703181.2017.1300620] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kristie J. Harper
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Annette D. Barton
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Chrianna Bharat
- University of New South Wales, Sydney, New South Wales, Australia
| | - Antonio C. Petta
- Area Rehabilitation and Aged Care, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Deborah G. Edwards
- Occupational Therapy, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Glenn Arendts
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Antonio Celenza
- Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
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Abstract
OBJECTIVE The purpose of this article is to introduce the reader to basic concepts of quality and safety in radiology. CONCLUSION Concepts are introduced that are keys to identifying, understanding, and utilizing certain quality tools with the aim of making process improvements. Challenges, opportunities, and change drivers can be mapped from the radiology quality perspective. Best practices, informatics, and benchmarks can profoundly affect the outcome of the quality improvement initiative we all aim to achieve.
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Mandatory Assignment of Modified Wells Score Before CT Angiography for Pulmonary Embolism Fails to Improve Utilization or Percentage of Positive Cases. AJR Am J Roentgenol 2016; 207:442-9. [DOI: 10.2214/ajr.15.15394] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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12
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Mansouri M, Aran S, Shaqdan KW, Abujudeh HH. Rating and Classification of Incident Reporting in Radiology in a Large Academic Medical Center. Curr Probl Diagn Radiol 2016; 45:247-52. [PMID: 27020256 DOI: 10.1067/j.cpradiol.2016.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/11/2016] [Indexed: 12/30/2022]
Abstract
The purpose of this article is to provide a rate of safety incident report of adverse events in a large academic radiology department and to share the various types that may occur. This is a Health Insurance Portability and Accountability Act compliant, institutional review board-approved study. Consent requirement was waived. All incident reports from April 2006-September 2012 were retrieved. Events were further classified as follows: diagnostic test orders, identity document or documentation or consent, safety or security or conduct, service coordination, surgery or procedure, line or tube, fall, medication or intravenous safety, employee general incident, environment or equipment, adverse drug reaction (ADR), skin or tissue, and diagnosis or treatment. Overall rates and subclassification rates were calculated. There were 10,224 incident reports and 4,324,208 radiology examinations (rate = 0.23%). The highest rates of the incident reports were due to diagnostic test orders (34.3%; 3509/10,224), followed by service coordination (12.2%; 1248/10,224) and ADR (10.3%; 1052/4,324,208). The rate of incident reporting was highest in inpatient (0.30%; 2949/970,622), followed by emergency radiology (0.22%; 1500/672,958) and outpatient (0.18%; 4957/2,680,628). Approximately 48.5% (4947/10,202) of incidents had no patient harm and did not affect the patient, followed by no patient harm, but did affect the patient (35.2%, 3589/10,202), temporary or minor patient harm (15.5%, 1584/10,202), permanent or major patient harm (0.6%, 62/10,202), and patient death (0.2%, 20/10,202). Within an academic radiology department, the rate of incident reports was only 0.23%, usually did not harm the patient, and occurred at higher rates in inpatients. The most common incident type was in the category of diagnostic test orders, followed by service coordination, and ADRs.
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Affiliation(s)
- Mohammad Mansouri
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shima Aran
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Khalid W Shaqdan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hani H Abujudeh
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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Mansouri M, Aran S, Shaqdan KW, Abujudeh HH. How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center. Eur Radiol 2015; 26:2064-72. [PMID: 26560719 DOI: 10.1007/s00330-015-4061-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/27/2015] [Accepted: 10/06/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Our goal is to present our multi-year experience in incident reporting in CT in a large medical centre. METHODS This is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment. RESULTS A total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death. CONCLUSION Our study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. KEY POINTS • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.
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Affiliation(s)
- Mohammad Mansouri
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA
| | - Shima Aran
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA
| | - Khalid W Shaqdan
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA
| | - Hani H Abujudeh
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA. .,Department of Radiology, Cooper University Hospital of Rowan University, One Cooper Plaza, Camden, 08103, NJ, USA.
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Mansouri M, Aran S, Harvey HB, Shaqdan KW, Abujudeh HH. Rates of safety incident reporting in MRI in a large academic medical center. J Magn Reson Imaging 2015; 43:998-1007. [DOI: 10.1002/jmri.25055] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 09/10/2015] [Accepted: 09/11/2015] [Indexed: 01/01/2023] Open
Affiliation(s)
- Mohammad Mansouri
- Department of Radiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts USA
| | - Shima Aran
- Department of Radiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts USA
| | - Harlan B. Harvey
- Department of Radiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts USA
| | - Khalid W. Shaqdan
- Department of Radiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts USA
| | - Hani H. Abujudeh
- Department of Radiology; Massachusetts General Hospital, Harvard Medical School; Boston Massachusetts USA
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15
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Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports. Emerg Radiol 2015; 22:623-30. [DOI: 10.1007/s10140-015-1336-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 07/24/2015] [Indexed: 12/22/2022]
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Reply to "the 'Abujudeh Curve' in radiology quality and safety research". AJR Am J Roentgenol 2015; 204:W607. [PMID: 25905971 DOI: 10.2214/ajr.14.14186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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