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Search results for "Health Care Executives and Administrators"

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  • Health Care Executives and Administrators
  • Radiology
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Journal Article > Study

Impact of an electronic alert notification system embedded in radiologists' workflow on closed-loop communication of critical results: a time series analysis.

  • Classic

Lacson R, O'Connor SD, Sahni VA, et al. BMJ Qual Saf. 2016;25:518-524.

Test result notification is a longstanding patient safety problem. This time series analysis examined changes in documented communication between the interpreting radiologist and the treating physician for abnormal test results following implementation of an electronic alert notification system. The system allows radiologists to send alerts within their workflow for synchronous communication via pager for critical results and asynchronous communication via email for abnormal but noncritical results with alerts persisting until acknowledged by treating physicians. The authors used an automated text searching algorithm to identify radiology reports with and without documented communication and employed manual record review and adjudication to detect abnormal findings. They found that the electronic alert system led to higher levels of documented communication for abnormal findings without increasing documented communication of normal reports, allaying concerns about alert fatigue. This work demonstrates how systems thinking about provider workflow can result in technology approaches to enhance safety.

Journal Article > Study

Collective intelligence meets medical decision-making: the collective outperforms the best radiologist.

  • Classic

Wolf M, Krause J, Carney PA, Bogart A, Kurvers RHJM. PLoS One. 2015;10:e0134269.

Collective intelligence encompasses several methods for summarizing input from multiple individuals, which can often be more accurate than any one expert. In this study, investigators applied several collective intelligence algorithms to mammography interpretation. They found that aggregating the interpretations of multiple radiologists resulted in higher accuracy—fewer false positive results and more true positive results—than even the most accurate single radiologist. This work builds on earlier studies of diagnostic accuracy in imaging studies. This study has profound implications for improving diagnosis through collaboration between clinicians in real time, perhaps facilitated through technology, as a complement to the long-standing diagnostic safety strategy of morbidity and mortality conferences, which provide group feedback once a case has concluded.

Journal Article > Commentary

Peer feedback, learning, and improvement: answering the call of the Institute of Medicine report on diagnostic error.

Larson DB, Donnelly LF, Podberesky DJ, Merrow AC, Sharpe RE Jr, Kruskal JB. Radiology. 2017;283:231-241.

Improving the culture of safety within health care is an essential component of preventing errors. This commentary discusses the culture of radiology in the context of recent progress in understanding and reducing diagnostic error. The authors suggest that peer-oriented feedback and assessment would drive progress in improving safety in radiology.

Journal Article > Commentary

Recommended responsibilities for management of MR safety.

Calamante F, Ittermann B, Kanal E, Norris D; Inter-Society Working Group on MR Safety. J Magn Reson Imaging. 2016;44:1067-1106.

Magnetic resonance safety events can lead to serious patient harm. This commentary provides recommendations from expert consensus to help organizations design and implement a range of magnetic resonance imaging services. The authors also define three levels of management responsibilities required to support those recommendations in a various settings.

Journal Article > Study

Effect of using the same vs different order for second readings of screening mammograms on rates of breast cancer detection: a randomized clinical trial.

Taylor-Phillips S, Wallis MG, Jenkinson D, et al. JAMA. 2016;315:1956-1965.

Interpretation of mammograms is a repetitive task, and a vigilance decrement—decreased attention after many repetitions of the same task—could impair diagnostic accuracy. However, this large randomized trial found no evidence for vigilance decrement. Investigators also determined that radiologists were equally accurate at identifying abnormalities regardless of the order in which they reviewed the studies.

Clinical Guideline

Society of Interventional Radiology IR Pre-Procedure Patient Safety Checklist by the Safety and Health Committee.

Rafiei P, Walser EM, Duncan JR, et al; Society of Interventional Radiology Health and Safety Committee. J Vasc Interv Radiol. 2016;27:695-699.

Most research has focused on developing and implementing checklists in surgical settings. This guideline recommends a set of pre-procedure checklist items and offers rationales for each to help hospitals develop a checklist for use in interventional radiology.

Journal Article > Study

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports.

Lauritzen PM, Andersen JG, Stokke MV, et al. BMJ Qual Saf. 2016;25:595-603.

Repeat interpretation of radiological images is known to yield more accurate diagnosis. Investigators interpreted more than 1000 abdominal CT scans twice and found clinically significant changes on the second read in 14% of cases. The authors suggest that using expert second radiology interpretation may enhance diagnostic accuracy.

Journal Article > Study

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering.

Kruger JF, Chen AH, Rybkin A, et al. BMJ Qual Saf. 2016;25:977-985.

Medical imaging overuse is associated with increased rates of cancer related to radiation exposure. Researchers found that displaying radiation exposure and cost information to clinicians ordering radiologic studies may affect their decision to request diagnostic imaging and raise clinician awareness around radiation risks and study costs.

Special or Theme Issue

Quality, Safety, and Noninterpretive Skills.

Kruskal JB, Kung JW, eds. Radiographics. 2015;35:1627-1848.

Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for providers and patients. Articles in this special issue explore noninterpretive skills in radiologic practice, such as root cause analysis, professionalism, and error identification and reduction.

Journal Article > Study

Evaluation of near-miss wrong-patient events in radiology reports.

Sadigh G, Loehfelm T, Applegate KE, Tridandapani S. AJR Am J Roentgenol. 2015;205:337-343.

Despite The Joint Commission requirement to use at least two patient identifiers when obtaining an imaging study, wrong-patient events still occur. This retrospective case review study determined the prevalence of reported near-miss wrong-patient events in radiology at two large academic hospitals. The overall event rate was 4 per 100,000 radiology studies.

Journal Article > Study

Impact and culture change after the implementation of a preprocedural checklist in an interventional radiology department.

Wong SSN, Cleverly S, Tan KT, Roche-Nagle G. J Patient Saf. 2015 Jul 31; [Epub ahead of print].

Checklists have played a leading role in the most significant successes of the patient safety movement. A periprocedural checklist was successfully implemented and well received by interventional radiology staff at a Canadian hospital, and it had no negative effects on physician or staff workflow.

Journal Article > Study

Improvement in detection of wrong-patient errors when radiologists include patient photographs in their interpretation of portable chest radiographs.

Tridandapani S, Olsen K, Bhatti P. J Digit Imaging. 2015;28:664-670.

This innovative pilot study found significant improvement in radiologists' ability to detect wrong-patient errors when patient photographs were provided with radiographs. The authors advocate for including photographs with portable radiographs to prevent patient mislabeling errors and augment safety.

Journal Article > Review

Risk management in radiology departments.

Craciun H, Mankad K, Lynch J. World J Radiol. 2015;7:134-138.

Increased radiation exposure has emerged as a patient safety problem, with the potential to result in harm for providers and patients. This review explores how risk management tactics can be applied to radiology work and suggests development of quality systems, enhanced competency, transparency, and evidence-based protocols as ways to augment radiation safety.

Journal Article > Commentary

A systems approach to evaluating ionizing radiation: six focus areas to improve quality, efficiency, and patient safety.

Perlin JB, Mower L, Bushe C. J Healthc Qual. 2015;37:173-188.

Radiation therapy has been described as an emerging patient safety issue due to harm associated with its use. This commentary describes a comprehensive analysis that identified risks related to ionizing radiation delivery and recommends solutions to enhance its safety.

Journal Article > Study

Emergency physicians' views of direct notification of laboratory and radiology results to patients using the internet: a multisite survey.

Callen J, Giardina TD, Singh H, et al. J Med Internet Res. 2015;17:e60.

Providing test results directly to patients is one way in which enhanced patient engagement could improve safety, as failure to appropriately follow up on test results is a recognized cause of diagnostic errors. Accomplishing this will require endorsement from physicians, and this survey examines the attitudes of Australian emergency physicians regarding direct provision of test results to patients. The majority of physicians expressed discomfort with patients having direct access to test results, mainly because physicians feared patients would experience undue anxiety or lack the knowledge necessary to interpret the results. More physicians supported providing patients with direct access to normal test results than abnormal test results, mirroring the findings of a prior survey of primary care providers. Physicians were more supportive of direct release of test results if it would decrease their own workload. The results of this survey reveal the need for careful exploration of the best methods to increase patient engagement without disregarding clinicians' concerns. A previous AHRQ WebM&M interview with Dave deBronkart discussed allowing patients to access their medical records.

Journal Article > Commentary

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2015;122:495-520.

This practice advisory summarizes the literature and expert opinion to advise practitioners on the dangers of administering anesthesia to patients receiving magnetic resonance imaging, or MRIs.

Web Resource > Multi-use Website

Radiation Oncology Incident Learning System.

American Society for Radiation Oncology and American Association of Physicists in Medicine.

Reporting of near misses and adverse events can provide a foundation for learning from error. This Web site supports an online portal facilitating incident reporting to enable data and experience analysis that will be used to inform development of guidelines and educational programs to promote safe practice in radiation oncology.

Journal Article > Study

Lack of timely follow-up of abnormal imaging results and radiologists' recommendations.

Al-Mutairi A, Meyer AND, Chang P, Singh H. J Am Coll Radiol. 2015;12:385-389.

This examination of abnormal imaging results found that patients recommended for additional imaging were often lost to follow-up. Because lack of timely follow-up can lead to delays in diagnosis, this work highlights a gap in current patient safety practices.

Journal Article > Study

Practice and quality improvement: successful implementation of TeamSTEPPS tools into an academic interventional ultrasound practice.

Gupta RT, Sexton JB, Milne J, Frush DP. AJR Am J Roentgenol. 2015;204:105-110.

This pre-post study found improvements in safety culture, as measured by the Safety Attitudes Questionnaire, following the implementation of AHRQ's TeamSTEPPS tools. These findings add to the body of research supporting teamwork training as a way to enhance safety.

Journal Article > Study

Do telephone call interruptions have an impact on radiology resident diagnostic accuracy?

Balint BJ, Steenburg SD, Lin H, Shen C, Steele JL, Gunderman RB. Acad Radiol. 2014;21:1623-1628.

Interruptions are inevitable for busy clinicians, and recently studies have shown that interruptions can increase workload for physicians and raise the risk of medication administration errors by nurses. However, these safety risks must be balanced against the fact that interruptions are often necessary for patient care. This study analyzed data from telephone logs and a formal quality assurance program to examine the effect of telephone interruptions on accuracy of on-call radiology residents' study interpretations. The authors found that a higher frequency of interruptions was associated with more diagnostic errors. This study is one of the first to document clinical consequences of physician interruptions and adds to our understanding of systems contributors to diagnostic errors. An incident involving an incorrect overnight radiology interpretation is discussed in a past AHRQ WebM&M commentary.

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