Failed Organizational and Departmental Processes May Lead to Wrong-Patient, Wrong-Procedure, Wrong-Side and Wrong-Site Errors in Radiology Services

Wednesday, June 1, 2011 General News
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The Pennsylvania Patient Safety Authority identified 652 events in Pennsylvania healthcare facilities in 2009


Pa., June 1, 2011 /PRNewswire-USNewswire/ -- The Pennsylvania Patient Safety Authority received 652 events from Pennsylvania healthcare facilities in 2009 that identified specific
failed processes within radiology procedures that exposed patients to potential harm, including order and scheduling inaccuracies, patient misidentification and inaccurate procedure verification processes.

Specifically, of the events reported to the Authority, 50% were related to wrong-procedure or test, 30% were related to wrong-patient, 15% were related to wrong-side and five percent were related to wrong-site radiology errors. The data was released today in the Authority's quarterly June Pennsylvania Patient Safety Advisory.

"Patient identification issues are well recognized as a challenge in the healthcare arena," Dr. John Clarke, clinical director of the Pennsylvania Patient Safety Authority said. "When you're dealing with a hospital setting it increases the risk of misidentification because of the numerous departments and healthcare personnel that are involved."

"There are strategies facilities can implement to minimize the risk as much as possible," Clarke added.

Strategies to prevent these types of errors are given in the Advisory, which cites the principles of the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™ outlined by the Joint Commission as transferrable to disciplines other than surgery to prevent unintended procedures and patient complications.

"These protocols, while targeted toward preventing surgery mistakes, can be used to standardize procedures in other areas of care to ensure that patients are accurately identified and procedures correctly scheduled and performed across-the-board, not just in the operating room," Clarke said. "An assessment tool, sample policy and teaching module of events with learning points are also available for patient safety officers to determine where their facility stands in regard to the likelihood of these events happening in their facility.

"The Authority has also developed consumer tips so patients and their loved ones understand how participating in their healthcare can make a difference," Clarke added.

For more information about the studies and data regarding radiology services go to the Advisory article "Applying the Universal Protocol to Improve Patient Safety in Radiology Services" at the Authority's website

The Authority's 2011 June Advisory also contains other clinical articles with toolkits for the healthcare provider to improve patient safety. Highlights include:

  • Reducing Errors in Blood Specimen Mislabeling: From August 2009 through October 2010, the Authority sponsored a multihospital blood specimen labeling collaborative. The Authority worked with hospitals to measure blood specimen labeling error rates, document hospital-specific interventions to reduce the labeling error rate, and measure the outcome of interventions. At the end of the collaborative, there was a 37% aggregate statistically significant decrease in specimen labeling errors. This article discusses the collaborative's objectives, methods and outcomes. A blood specimen investigation toolkit is also available on the Authority's website, along with a "Did You ID Me?" poster and button for facilities to raise awareness about the issue.
  • Program Promotes the Establishment of Hospital VTE Prevention Programs: The Agency for Healthcare Research and Quality reports that efforts to reduce the number of venous thromboembolism (VTE) can result in substantial reductions in morbidity and mortality in addition to substantial cost savings. Highmark's QualityBLUE Hospital Pay-for-Performance Program has targeted improvements in averting VTE with 25 hospitals in its service area. The successful application of processes that are unique to the individual hospitals and in alignment with best practices has resulted in an 18% decrease in the deep venous thrombosis (DVT) rate and a 21% decrease in the pulmonary embolism (PE) rate in participating hospitals. The total cost of preventing 77 DVT cases and 63 PE cases was projected at nearly $2 million. This article discusses the scope of the problem and gives more details of the program to prevent them, along with lessons learned.  
  • Bloodborne Disease Transmission Associated with Unsafe Injection Practices: Lapses in basic safe injection practices and infection control expose patients to needless risk of transmission of bloodborne pathogens. The Centers for Disease Control and Prevention (CDC) and U.S. public health officials identified 51 reports of outbreaks of hepatitis B virus and hepatitis C virus infection primarily associated with unsafe injection practices in patients in the United States from 1998 through 2009. Of the 75,000 patients who were placed at risk, 620 became infected or died as a result of the exposure. Events of unsafe syringe reuse reported to the Authority were associated with delivery of injectable medications during surgery, vaccinations, and bedside care. This article gives strategies for healthcare facilities to reduce the risk of bloodborne pathogen transmission through injection and explains key components of an infection prevention program.
  • Data Snapshot of Errors Involving Methotrexate: Methotrexate  is a drug used to treat patients with a variety of illnesses including cancer, psoriasis, severe rheumatoid arthritis, lupus and multiple sclerosis. Other uses include treatment of Crohn's disease, ectopic pregnancy, inflammatory myositis, myasthenia gravis, Takayasu arteritis and asthma. Authority reports from June 2004 through July 2010 show the drug dosage, daily or weekly, is sometimes confused by clinicians causing patients to become more ill or even die as a result. Roughly 20% of reported events involving methotrexate were identified as wrong doses/overdosages. This article breaks down the data and gives reasons behind the mix-ups allowing healthcare facilities to take a look at their own processes for communication gaps when dispensing medications.
  • Wrong-Site Surgery Update: Wrong-site surgery continues to occur in Pennsylvania. This update focuses on knowledge about doing a time-out effectively. It also addresses a question about the value of reviewing imaging studies in the operating room (OR). An updated toolkit is also available on the Authority's website for healthcare facilities to prevent wrong-site surgery.

For the complete 2011 June Pennsylvania Patient Safety Advisory, go to

SOURCE Pennsylvania Patient Safety Authority


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