Reporting the reported – An analysis of the incidents for a hospital based MRI unit

This EPOS poster will be available online until July 20, 2020.

Congress:

ECR 2020

Poster Number:

C-04372

Type:

Educational Exhibit

Keywords:

MRI, Computer applications, Management, Radiographers, MR, PACS, RIS, Education, Ethics, Health policy and practice, Education and training, Occupational / Environmental hazards, Workforce, Retrospective, Not applicable, Performed at one institution

Authors:

A. Exconde, B. Walter; London/UK

DOI:

10.26044/ecr2020/C-04372

DOI-Link:

https://dx.doi.org/10.26044/ecr2020/C-04372

Table 1: Table 1 demonstrates the number of incidents filed from December 2017 to...

Table 2: Table 2 shows the top 4 primary incidents with their secondary incident...

Table 3: Table 3 exhibits the primary incidents involving patients

Learning objectives

Incident reporting is encouraged to improve patient safety. A review was conducted to identify and learn any themes or trends that could pose harm to either patients or staff [1]. An assessment of incident reports provides valuable awareness into quality improvements that can be made within an imaging service [2]. Understanding the various types and frequency of incidents that arise is important to learn from and share with others to prevent future incidents [3].

Background

The aim is to present a full years’ experience of online incident reporting related to a Magnetic Resonance Imaging (MRI) unit within a 670-bed capacity hospital [4] with three MRI machines, one of which is a sought-after open MRI. This was an institutional evaluation of incident report data collected during the study period of December 2017 to November 2018. All incident reports logged during the study period were related to the MRI unit only. Incident reports were processed using an online platform (Sentinel) then categorised...

Findings and procedure details

The total number of incident reports in the study period between December 2017 to November 2018 hospital-wide was 224 on a total of 18,623 MRI patient scanned – an incidence rate of 1.2%. Wherein in 16,958 (91.06%) were outpatients, 1665 (8.94%) were inpatients, with May having the highest number of logged incidents with 34 (15.18%). Given its availability, 33 (14.73%) were open MRI related incidents. Most of the reports were made by clinical staff (98.66%) and the remaining were by the administration team. Table 1...

Conclusion

Unexpectedly, incident reports ensue at significantly higher rates with inpatients foremost attributed to patient transition and identification which fortuitously has not resulted in any patient harm or lawful consequences. This was followed by booking issues, mostly for open MRI options. Surprisingly, MRI safety incidents were comparatively middling and occasional, in addition, equipment issues were also regularly reported for the study period.

Personal information and conflict of interest

A. Exconde; London/UK - nothing to disclose B. Walter; London/UK - nothing to disclose

References

Smith AF. Patient safety: people, systems and techniques, Acta Anaesthesiol Scand, 2007, vol.51 (pg. 51-3) Leape LL. Error in medicine, J Am Med Assoc, 1994, vol. 272(pg. 1851 -7) RooksbyJ, Gerry B, Smith AF. Incident reporting schemes and the need for a good story, Int J Med Inform, 2007, vol. 76 (pg. 205-11) [PubMed] https://www.cqc.org.uk/sites/default/files/new_reports/AAAD6840.pdf https://journals.lww.com/ejanaesthesiology/Fulltext/2011/01000/Complaints_and_incident_reports_related_to.7.aspx Schultz, S.R, Watson, R.E, Prescott, S.L, Krecke, K.N, Aakre, K.T, Islam, M.N. & Stanson, A.W. (2011) Patient Safety Event Reporting in a Large Radiology Department. AJR; 197: 684-689. Carlfjord,...