Clinical Risk Management in radiology. Part II: applied examples and concluding remarks

Centonze, Maurizio; Visconti, D; S, Doratiotto; Silverio, R; Fileni, Adriano; Pescarini, Luigi; Golfieri, Rita

doi:10.1007/s11547-010-0579-z

Cited by 5 publications

(5 citation statements)

References 18 publications

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“…In the literature only a precedent similar study was individuated; Centonze et al [8], with the aim of providing a clearer understanding of the tools used for evaluating risk in the radiological setting, perform a proactive analysis applied to CT, and a reactive analysis was performed following a sentinel event triggered by a CT study allocated to the wrong patient in the RIS-PACS system. Centonze et al [8] conclude that the reactive analysis of the principal critical radiological elements that contributed to the sentinel event emphasizes the pressing need to change the management of CT healthcare services about RIS-PACS system.…”

Section: Discussionmentioning

confidence: 99%

“…Centonze et al [8] conclude that the reactive analysis of the principal critical radiological elements that contributed to the sentinel event emphasizes the pressing need to change the management of CT healthcare services about RIS-PACS system.…”

Section: Discussionmentioning

confidence: 99%

“…PRIs obtained were sorted in descending order; the critical threshold for each PRI has been chosen using the Pareto criterion: a value >200 corresponds to a high risk, a value >100 corresponds to a medium risk, a value >50 corresponds to a low risk, and a value <50 corresponds to a very low risk [8]. …”

Section: Methodsmentioning

confidence: 99%

“…A careful analysis must aim to identify risks related to the management of all phases of a process of radiological diagnosis, for measuring and setting actions for prevention and control [8–11]. …”

Section: Introductionmentioning

confidence: 99%

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Risk Management in Magnetic Resonance: Failure Mode, Effects, and Criticality Analysis

Petrillo

Fusco

Granata

et al. 2013

BioMed Research International

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The aim of the study was to perform a risk management procedure in “Magnetic Resonance Examination” process in order to identify the critical phases and sources of radiological errors and to identify potential improvement projects including procedures, tests, and checks to reduce the error occurrence risk. In this study we used the proactive analysis “Failure Mode Effects Criticality Analysis,” a qualitative and quantitative risk management procedure; has calculated Priority Risk Index (PRI) for each activity of the process; have identified, on the PRI basis, the most critical activities and, for them, have defined improvement projects; and have recalculated the PRI after implementation of improvement projects for each activity. Time stop and audits are performed in order to control the new procedures. The results showed that the most critical tasks of “Magnetic Resonance Examination” process were the reception of the patient, the patient schedule drafting, the closing examination, and the organization of activities. Four improvement projects have been defined and executed. PRI evaluation after improvement projects implementation has shown that the risk decreased significantly following the implementation of procedures and controls defined in improvement projects, resulting in a reduction of the PRI between 43% and 100%.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Risk Management in Magnetic Resonance: Failure Mode, Effects, and Criticality Analysis

Petrillo

Fusco

Granata

et al. 2013

BioMed Research International

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“…In our digital era, however, the speed and ubiquity of transmission of radiological information to other departments such as operating rooms, has added a critical determinant when the information is affected by errors, incomplete, or unavailable [3][4][5][6][7][8].…”

Section: Introductionmentioning

confidence: 99%

Efficiency and Effectiveness of an Innovative RIS Function for Patient Information Reconciliation Directly Integrated with PACS

et al. 2012

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In RIS-PACS systems, potential errors occurring during the execution of a radiologic examination can amplify the clinical risks of the patient during subsequent treatments, e.g., of oncologic patients or of those who must do additional treatments based on the initial diagnosis. In Reggio Emilia Province Diagnostic Imaging Department (REDID) we experienced different strategies to reduce clinical risks due to patient reconciliation errors. In 2010, we developed a procedure directly integrated in our RIS-PACS that uses Health Level 7 (HL7) standard messaging, which generates an overlay with the text "under investigation" on the images of the study to be corrected. All the healthcare staff is informed of the meaning of that overlay, and only the radiologist and the emergency services staff can consult these images on PACS. The elimination of image overlay and of any access limitation to PACS was triggered to confirm of the right correction made by RIS-PACS system administrator (SA). The RIS-PACS integrated tool described in this paper allows technologists and radiologists to efficiently highlight patient exam errors and to inform all the users to minimize the overall clinical risks, with a significant savings in costs. Over the years, we have observed a steady decrease in the percentage of reconciled studies. Error reconciliation requires an effective and efficient mechanism. The RIS-PACS integrated tool described in this paper enables technologists and radiologists to quickly and efficiently highlight patient exam errors and inform all the users. Next generation of RIS-PACS could be equipped with similar reconciliation tools.

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La gestione del rischio nella diagnostica per immagini: radiologia

Bibbolino¹,

Canitano

Vimercati³

2013

Prevenire Gli Eventi Avversi Nella Pratica Clinica

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Clinical Risk Management in radiology. Part II: applied examples and concluding remarks

Cited by 5 publications

References 18 publications

Risk Management in Magnetic Resonance: Failure Mode, Effects, and Criticality Analysis

Risk Management in Magnetic Resonance: Failure Mode, Effects, and Criticality Analysis

Efficiency and Effectiveness of an Innovative RIS Function for Patient Information Reconciliation Directly Integrated with PACS

La gestione del rischio nella diagnostica per immagini: radiologia

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