Detecting Patient Safety Errors by Characterizing Incidents Reported by Medical Imaging Staff

Abstract

The objectives of the study were to characterize events related to patient safety reported by medical imaging personnel in Finland in 2007–2017, the number and quality of reported injuries, the risk assessment, and the planned improvement of operations. The information was collected from a healthcare patient safety incident register system. The data contained information on the nature of the patient safety errors, harms and near-misses in medical imaging, the factors that lead to the events, the consequences for the patient, the level of risks, and future measures. The number of patient safety incident reports included in the study was 7,287. Of the incident reports, 75% concerned injuries to patients and 25% were near-misses. The most common consequence of adverse events and near-misses were minor harm (37.2%) related to contrast agent, or no harm (27.9%) related to equipment malfunction. Supervisors estimated the risks as low (47.7%) e.g., data management, insignificant (35%) e.g., verbal communication or moderate (15.7%) e.g., the use of contrast agent. The most common suggestion for learning from the incident was discussing it with the staff (58.1%), improving operations (5.7%) and submitting it to a higher authority (5.4%). Improving patient safety requires timely, accurate and clear reporting of various patient safety incidents. Based on incident reports, supervisors can provide feedback to staff, develop plans to prevent accidents, and monitor the impact of measures taken. Information on the development of occupational safety should be disseminated to all healthcare professionals so that the same mistakes are not repeated.

Safety Incidents in Psychiatric Inpatient Care: A Qualitative Content Analysis of Safety Incident Reports

“…Safety incidents have multidimensional negative consequences on the well-being of patients and staf [5,6] and on organizational operations [7]. To improve safety, it is important to learn about the causes of incidents and use this knowledge to develop systems of care [8]. Moreover, to ensure safety on psychiatric wards, methods for risk assessment and prevention of aggressive behaviour must be up-to-date.…”

Segurança Do Paciente Em Serviços De Medicina Nuclear: Uma Revisão Sistemática

“…Cada relatório recebeu uma pontuação relacionada ao dano de 0 a 4, qual 0 é atribuído a ausência de dano ao paciente, 1 é relacionado a ausência de dano, mas atingiu a paciente, 2 se refere a um dano temporário, 3 a um dano permanente e 4 representa morte. Dos 11.570 relatórios de segurança apresentados, 854 (7%) foram relacionados ao diagnóstico por imagem, que estão atribuídos a componentes multifatoriais do sistema de trabalho, como: pessoa, tarefa, tecnologia, organização e ambiente.Em um estudo similar, na Finlândia,Tarkiainen et al, (2022) avaliaram 7.287 eventos relacionados a SP de 2007 a 2017, em um site de registro de incidentes. Os dados continham informações sobre a natureza dos erros de SP, danos e quase acidentes em imagens médicas, os fatores que levam aos eventos, as 43 consequências para o paciente, o nível de riscos e medidas futuras.…”