A national study of the causes, consequences and amelioration of adverse events in the use of MRI, CT, and conventional radiography in Norway

摘要

Background Rapid technological developments, increased complexity, and increased demand have made patient safety a challenge in radiology. Purpose To uncover the causes and consequences behind patient injury compensation claims in the use of MRI, CT, and conventional X-ray examinations, and to determine the system factors that need to be focused on in order to prevent these events. Material and Methods This descriptive cross-sectional study uses data acquired from The Norwegian System of Patient Injury Compensation. A total of 240 cases from 2012-2016 were included. Results According to our study, the main factors contributing to patient injury compensation claims in radiology were false-negative findings (48.7%), misinterpretation (13.1%), and "satisfaction of search" (12%). Another source of error was routines (8.7%), mainly where the patient should have been (further) examined using another modality. Other causes were related to communication (7.6%), procedures (2.9%), technical factors (2.5%), organizational and management factors (1.5%), competence (0.7%), location of the lesion (0.7%), patient factors (0.7%), false-positive findings (0.4%), and work environment (0.4%). These events led to delayed diagnosis and/or treatment in the range of 0-3650 days. Conclusion Errors of perception (false negative and "satisfaction of search") and cognitive errors (misinterpretation) were the main reasons behind patient injury compensation claims in radiology. We suggest that a combination of double-reading, specialization, increased collaboration between professionals, as well as a reduction of unnecessary examinations should be considered to reduce adverse events in radiology.