FORMAT REVIEW ARTICLE

TITLE ARTICLE: Evaluation of Near-Miss Wrong-Patient Events in Radiology Reports

Nama Mahasiswa: Cornel Anggara
URL: https://www.ncbi.nlm.nih.gov/pubmed/26204284 NIM : 2017 1030009
SECTION PURPOSE

ABSTRACT The purpose of this study was to estimate the prevalence of reported mis
wrong patient event in radiology. An institutional imaging report database
was searched for reports between January 1, 2009, and May 30, 2013.
Overall, 67 eligible report were identified among 1,717,713 examinations
performed during the study period. The number of near-miss mislabelled
patient events for imaging test and the delay in awereness of these events
were substantial, especially for radiography.

INTRODUCTION The purpose of this study was to estimate the prevalence of reported
nearmiss wrong-patient events in radiology at two large academic hospitals
and its relation to imaging modality, clinical setting, and time of
occurrence.

METHODS These imaging reports were categorized into either mislabeled or

misidentified patient or wrong dictation or report events. The mislabeling-
misidentification events involved patients whose images were incorrectly
placed in another patients folder. In wrong dictation or report events, a
patients images were placed in the correct imaging folder, but another
patients images were used in error for dictation of the report. The time to
detect each of these events was also evaluated

RESULTS Overall, 67 eligible reports were identified among 1,717,713 examinations

performed during the study period. The estimated event rate was 4 per
100,000 examinations (mislabeling-misidentification, 52%; wrong
dictation, 48%). The monthly mean of mislabeling-misidentification
events was 0.7 (SD, 0.9) and of wrong dictation events was 0.6 (SD, 0.7).
The median time for mislabeling-misidentification reports to be identified
was 22 hours and for wrong dictation reports was 0 hours. Portable chest
radiography was the modality involved in 69% (24/35) of reported
mislabeling-misidentification and 44% (14/32) of wrong dictation events
 (p = 0.08); 43% (15/35) of mislabeling-misidentification and 28% (9/32)
of wrong dictation events occurred during off hours; 63% (22/35) of
mislabeling-misidentification and 56% (18/32) of wrong dictation events
occurred in the inpatient setting.

DISCUSSION The results of our study showed that the average monthly incidence of
near-miss wrongpatient events is 0.7 (SD, 0.9) for
mislabelingmisidentification events and 0.6 (SD, 0.7) for wrong dictation
events. Even after adjustment for the volumes of each modality performed,
portable chest radiography had the most mislabeling-misidentification
events. The time from occurrence to identification of wrong dictation
events was significantly less than that for mislabeling-misidentification
events (median time, 0 vs 22 hours; p = 0.02)

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