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Approach to Improving Safety
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Search results for "United States of America"

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Web Resource > Multi-use Website

Radiotherapy Incident Reporting and Analysis System.

Center for Assessment of Radiological Sciences.

Patient Safety Organizations enable robust data collection and analysis to support learning from medical error. This website of a Patient Safety Organization dedicated to radiation safety improvement offers a mechanism for voluntary reporting of radiation oncology incident data, a searchable database, and related publications.

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.

Web Resource > Government Resource

Interference between CT and Electronic Medical Devices.

Rockville, MD: Center for Devices and Radiological Health, US Food and Drug Administration. April 12, 2016.

This website alerts clinicians and patients to risks for patient harm associated with implanted electronic medical devices, such as insulin infusion pump and pacemakers, when x-rays are used during CT examinations.

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.

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

Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system.

Ford EC, Smith K, Harris K, Terezakis S. Med Phys. 2012;39:6968-6971.

Analysis of voluntarily reported errors in radiation therapy treatments resulted in systematic changes to treatment planning and delivery. After the system improvements were implemented, no similar errors occurred and multiple near misses were detected before patients were affected.

Journal Article > Study

How radiation oncologists would disclose errors: results of a survey of radiation oncologists and trainees.

Evans SB, Yu JB, Chagpar A. Int J Radiat Oncol Biol Phys. 2012;84:e131-e137.

This study surveyed radiation oncologists about their disclosure practices, which were notable for high rates of full disclosure but lack of consistency on actual practices.

Journal Article > Study

Quantitative assessment of workload and stressors in clinical radiation oncology.

Mazur LM, Mosaly PR, Jackson M, et al. Int J Radiat Oncol Biol Phys. 2012;83:e571-e576.

This assessment of stressors and workload among radiation oncology providers highlighted the importance of interruptions, technical issues (e.g., software malfunctions), and teamwork failures as key contributing factors.

Journal Article > Review

Radiation Therapy Safety: The Critical Role of the Radiation Therapist.

Odle TG, Rosier N. Albuquerque, NM: American Society of Radiologic Technologists Education and Research Foundation; 2012.

Summarizing the role of radiation therapists and challenges they face, this white paper details best practices in training, skills assessment, workplace culture, and workplace staffing to address safety concerns in radiation therapy.

Journal Article > Commentary

Image Gently, Step Lightly: promoting radiation safety in pediatric interventional radiology.

Sidhu M, Goske MJ, Connolly B, et al. AJR Am J Roentgenol. 2010;195:W299-W301.

This commentary describes a checklist initiative to standardize workflow, promote team responsibility, and improve the safety of pediatric radiology procedures.

Press Release/Announcement

CT brain perfusion scans safety investigation: initial notification.

MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; October 9, 2009.

This announcement informs professionals of a potential safety hazard when using CT brain perfusion scans to aid in the diagnosis of stroke. At one facility, patients received excessive doses of radiation.

Journal Article > Study

Adverse event protocol for interventional pain medicine: the importance of an organized response.

Sitzman BT. Pain Med. 2008;9:S108-S112.

This study describes implementation of a standardized protocol for responding to adverse events associated with interventional pain procedures.

Legislation/Regulation

Preventing accidents and injuries in the MRI suite.

Sentinel Event Alert. February 14, 2008;(38):1-3.  

This alert provides risk reduction strategies and recommendations to minimize opportunities for failures associated with the use of magnetic resonance imaging (MRI).

Journal Article > Study

Enhancing pediatric safety: using simulation to assess radiology resident preparedness for anaphylaxis from intravenous contrast media.

Gaca AM, Frush DP, Hohenhaus SM, et al. Radiology. 2007;245:236-244.

This study developed a simulation model in the radiology environment and identified the need for greater resuscitation aids to treat unexpected clinical events. A past AHRQ WebM&M commentary discussed the role of simulation as a method to practice both behavioral and technical skills.

Journal Article > Commentary

Root cause analysis.

Stecker MS. J Vasc Interv Radiol. 2007;18:5-8.

The author provides an introduction to root cause analysis and its application to study and prevent medical error.

Newspaper/Magazine Article

Taking risky business out of the MRI suite.

Rozovsky FA, Gilk TB, Latino RJ. Mater Manag Health Care. 2006;15:18-23.

This article discusses risk management in magnetic resonance imaging facilities and the use of root cause analysis to inform risk management methodologies.

Newspaper/Magazine Article

Error rate greatest in hospital radiology.

Stein R. The Washington Post. January 18, 2006:A03.

This article reports on an analysis of data collected by United States Pharmacopeia's voluntary reporting program that found medication errors are seven times more likely to occur during radiological procedures.

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