Using near-miss events to improve MRI safety in a large academic centre

Goolsarran, Nirvani; Martinez, J. Mota; Garcia, Christine

doi:10.1136/bmjoq-2018-000593

Cited by 7 publications

(17 citation statements)

References 1 publication

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“…We excluded another 337 articles after reviewing the full-text citations largely because they neither identified individual NEs nor specified an existing framework (47%), or because they were non-scholarly (eg, media releases; 30%). Thus, our analyses were based on 367 articles 3 4 7–11 18–377. A full list of these articles and the information we extracted from them are found in online supplemental tables 1 and 2.…”

Section: Resultsmentioning

confidence: 99%

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

et al. 2023

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BackgroundNever events (NEs) are patient safety incidents that are preventable and so serious they should never happen. To reduce NEs, several frameworks have been introduced over the past two decades; however, NEs and their harms continue to occur. These frameworks have varying events, terminology and preventability, which hinders collaboration. This systematic review aims to identify the most serious and preventable events for targeted improvement efforts by answering the following questions: Which patient safety events are most frequently classified as never events? Which ones are most commonly described as entirely preventable?MethodsFor this narrative synthesis systematic review we searched Medline, Embase, PsycINFO, Cochrane Central and CINAHL for articles published from 1 January 2001 to 27 October 2021. We included papers of any study design or article type (excluding press releases/announcements) that listed NEs or an existing NE framework.ResultsOur analyses included 367 reports identifying 125 unique NEs. Those most frequently reported were surgery on the wrong body part, wrong surgical procedure, unintentionally retained foreign objects and surgery on the wrong patient. Researchers classified 19.4% of NEs as ‘wholly preventable’. Those most included in this category were surgery on the wrong body part or patient, wrong surgical procedure, improper administration of a potassium-containing solution and wrong-route administration of medication (excluding chemotherapy).ConclusionsTo improve collaboration and facilitate learning from errors, we need a single list that focuses on the most preventable and serious NEs. Our review shows that surgery on the wrong body part or patient, or the wrong surgical procedure best meet these criteria.

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Section: Resultsmentioning

confidence: 99%

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

et al. 2023

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“…Eight articles defined or described near misses as situations where events had not reached the patients 30,32,33,35–39 . Ten articles defined or described near misses that included events that had reached patients 31,34,40–45 and could be considered to potentially cause harm 46,47 .…”

Section: Resultsmentioning

confidence: 99%

The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

2022

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Objectives: For years, health care has recognized that learning from near misses offers potential opportunities to reduce unintended harm to patients. However, these benefits have yet to be realized. It is assumed that effective actions are being implemented as a result of learning from healthcare near misses, leading to improvements in patient safety. A scoping review of the healthcare literature was undertaken to explore the value of learning from near misses in the improvement of patient safety. Methods:The scoping review was conducted on Ovid MEDLINE, Embase, and CINAHL. Eligible articles published since 2000 were included.Results: A total of 4745 articles were identified through the searches, with 19 included in the final review. The articles included one randomized control trial. All the included articles had evidence of action after reporting or investigation of near misses, with the majority showing evaluation of impact. Actions were human, administrative, and engineering focused. Impact evaluation focused on the reduction of near misses, but without consideration of patient safety outcome measures, such as harm. The review also noted limited availability of experimental research and variability in near-miss definitions and that actions are not just the result of near misses.Conclusions: Currently, health care assumes that reporting and learning from near misses improves patient safety. The literature provides limited evidence supporting these assumptions and shows that actions as a result of near misses are commonly aimed at the human. There is a need to prove the benefits of focusing on near misses in health care and for more system-level actions.

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“…Preventing potentially hazardous events necessitates application of possible MR imaging safety interventions including thorough screening of patients and personnel, the availability of ferromagnetic detection devices and warning signs, and strict adherence to the patient-gowning policy. 43 Before scheduling an MRI, the first level of screening should ideally begin with a preliminary evaluation of the referring physician. The second critical level of screening begins when the patient arrives at the MRI screening area (Zone II) to fill out the MRI screening form.…”

Section: Discussionmentioning

confidence: 99%

MRI Safety Practice Observations in MRI Facilities Within the Kingdom of Jordan, Compared to the 2020 Manual on MR Safety of the American College of Radiology

Ayasrah¹

2022

MDER

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Purpose The absence of ionizing radiation in MRI applications does not guarantee absolute safety. Implementing of safety guidelines can ensure high-quality practice in the clinical MRI with the minimum risk. For this purpose, this cross-section quantitative study conducted in Jordan Kingdom aimed to assess current MRI safety guidelines in comparison with those of 2020 Manual on MR Safety of the American College of Radiology (ACR). Patients and Methods A site observation study of 38 MRI units was undertaken in June 2021. A well-structured MRI safety questionnaire was the primary data collection method. Data were subjected to a descriptive statistics content analysis by the SPSS version 20. The results were analyzed to yield comprehensive discussions. Results A total of 38 MRI facilities in participated in this study with the responding rate of 44.7%. Patient screening areas and changing rooms were available in about 29% (11/38) of the MRI facilities. Most facilities (55%, 21/38) conducted verbal screening only whereas 21% implemented both written and verbal screening for their patients and companions in zone II, which was present in a percentage of 29% in the approached facilities. Meanwhile, only 13 (43.2%) of 38 facilities used handheld magnets for physical screening, 25 (65.8%) of MRI units did not use any kind of ferromagnetic metal detection systems. Three (7.9%) participating centers had MR-safe wheelchairs, ventilators, anesthesia machines, and stretchers. Most MRI facilities participating in this study (71%) had emergency preparedness plans for alternative power outages. Despite a relatively low number of participating centers having an emergency exit or code (26.3% and 10.5%, respectively), none of them performed practice drills for such scenarios. Conclusion Investing in new MR-safe equipment requires introducing ferromagnetic detecting systems. More research is needed to establish the degree of MRI professional’s safety-related education.

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Using near-miss events to improve MRI safety in a large academic centre

Cited by 7 publications

References 1 publication

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

Identifying a list of healthcare ‘never events’ to effect system change: a systematic review and narrative synthesis

The Value of Learning From Near Misses to Improve Patient Safety: A Scoping Review

MRI Safety Practice Observations in MRI Facilities Within the Kingdom of Jordan, Compared to the 2020 Manual on MR Safety of the American College of Radiology

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