Human errors are inevitable. We must view errors primarily as a failure to provide a work environment that automatically detects and corrects human errors before they harm patients.

— Curtis P. Langlotz, M.D., Ph.D.

Radiology Plays Important Role in Overall Patient Safety

Curtis P. Langlotz, M.D., Ph.D. University of Pennsylvania in Philidelphia

Radiologists can help prevent medical errors and help improve patient safety, according to experts who spoke at RSNA 2005 during a special focus session.

“As we increasingly rely on information technology, the proper design and integration of computer systems can prevent our natural human limitations from precipitating harm to patients,” said Curtis P. Langlotz, M.D., Ph.D., moderator of the session, “Medical Errors and Patient Safety in Radiology.”

“Safety is a team effort and radiology needs to partner with the rest of the organization to improve safety,” said David W. Bates, M.D., chief of the division of general medicine at Brigham and Women’s Hospital and medical director of clinical and quality analysis for Partner's Healthcare Systems in Boston.

“Improvement involves combining technical solutions with improvement in safety culture,” Dr. Bates said. “Everybody has to be dedicated to improve the safety of care. Putting in place new technical solutions will not make a difference without the safety culture.”

Ramin Khorasani, M.D., vice-chairman of radiology, director of the Center for Evidence-Based Imaging and director for medical imaging information technology (IT) at Brigham and Women’s, said that appropriate planning and forethought need to be employed when adding IT systems to an existing radiology department or clinic.

“Significant resources are needed to manage the change into new electronic and digital environments,” he said. “Purchasing IT by itself is unlikely to bring significant results without investing in the resources to deal with the process and then communicating the process to all those involved. These issues have to be addressed for technology to succeed.” 

The Role of Radiology

In the interest of patient safety, healthcare professionals should focus on improving their ability to do the right thing in the right way, the group agreed. In radiology this means that the correct test is given to the correct patient and abnormal findings are communicated to referring physicians in a timely manner.

Dr. Khorasani said that doing the right things right also requires understanding patient clinical profiles. “In many instances, radiologists need to have the patient’s medical history—medication allergies, IV contrast allergies, medical conditions, cardiac and renal status, and the reason for the current test. This not only improves medical safety, but it also can help produce higher quality radiology reports,” he said.

Dr. Bates recommended implementing a system to ensure that referring physicians are aware of abnormal test results so that follow-up testing can be scheduled. He said that critical results need to be communicated immediately to responsible providers. This may require a separate, speedier system from the conventional one.

“All organizations have some tools in place for this, but critical results and abnormal findings can fall through the cracks,” Dr. Bates added.

“Merely interpreting an abnormal test does not make it known in the system,” explained Dr. Khorasani. “We need to get from a blob of text to a flag that says this patient needs something. In most radiology departments flagging patients is a manual process. For instance, I typically page the referring physician and wait for a call back. I think this is an area where technology can help increase medical safety.”

Dr. Khorasani suggested that other areas of radiology could benefit from a coding system such as the Breast Imaging Reporting and Data System (BI-RADS^®). Using BI-RADS, a single button click identifies findings in a variety of ways. For instance, “abnormal exam requiring follow up” or “worrisome for malignancy” can be coded with a keystroke. “BI-RADS has closed the loop on identifying abnormal mammograms and notifying the referring physician and auditing,” he said.

A smaller but equally important issue is proper patient identification, which is receiving attention in all areas of patient safety. Image labeling also should be addressed. “It’s easy to flip certain radiographs, so it is essential to make sure that the correct side is labeled,” said Dr. Bates. “All radiology departments should work on identification and labeling.”


David W. Bates, M.D. (left), and Ramin Khorasani, M.D., from Brigham and Women's Hospital participated in a special focus session on patient safety in radiology at RSNA 2005.

What Can Be Done

Most institutions have policies and procedures to deal with these issues. Dr. Bates said that, typically, these systems are not truly adequate to provide high levels of reliability.

“We have to put in systems that are better,” said Dr. Bates. “For example, it is important for all organizations to have tools to identify which physician is associated with which patient. Most organizations don’t do this very well. Organizations should ensure that abnormal results get appropriate follow up. That responsibility doesn’t have to sit within radiology, but radiology needs to have systems in place to make sure all the important results get communicated to the key person.”

Dr. Bates suggested a bar coding system that, in addition to patient identification, could be useful to ensure the safe delivery of medications and to connect laboratory tests and results to the correct patient.

“Some systems are more difficult to implement than others,” he explained. “Bar coding requires a substantial investment. Making sure a good database is available to physicians is not hard, but it does take initiative. Ensuring that all the abnormal radiology results get follow up is also not that difficult, but again, it takes initiative and effort.”

Dr. Khorasani said it is critical to make sure imaging information—reports and images—are available in real time at the point of care for referring physicians who are making clinical decisions. He notes that many institutions now have electronic access to radiology information.

While Dr. Bates cautioned that older systems require updates, he said older systems can be useful if the right solutions are installed around them.

“No human being can perform a task perfectly every time—not even a well-trained, disciplined radiologist,” said Dr. Langlotz, an associate professor of radiology and chief of health services research at the University of Pennsylvania in Philadelphia. “Human errors are inevitable. We must view errors primarily as a failure to provide a work environment that automatically detects and corrects human errors before they harm patients. The objective study of errors provides an opportunity to improve our information systems and our work processes to prevent future errors. The aviation industry is one good model for this approach.”To view the abstract for the RSNA 2005 special focus session, go to rsna2005.rsna.org/rsna2005/V2005/conference/event_display.cfm?em_id=4404461.