How often are Patients Harmed When They Visit the Computed Tomography Suite? A Multi-year Experience, in Incident Reporting, in a Large Academic Medical Center.

Mohammad Mansouri, Shima Aran, Khalid W Shaqdan, Hani H Abujudeh

Abstract read

In one paragraph

Article in European radiology, 2016. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 1 paper.

0numbers the graph read from it

0cells of the map it votes in

1citing papers in PubMed

–field-weighted citation impact

1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

The trial behind it

Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.

Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

1 citing paper in PubMed.

Detecting Patient Safety Errors by Characterizing Incidents Reported by Medical Imaging Staff.Frontiers in public health · 2022
Article

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

4 authors.

Mohammad MansouriDepartment of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA.

Shima AranDepartment of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA.

Khalid W ShaqdanDepartment of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA.

Hani H AbujudehDepartment of Radiology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Founders Building, Room 210, Boston, 02114, MA, USA. haniabujudeh@gmail.com.

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

objectivesOur goal is to present our multi-year experience in incident reporting in CT in a large medical centre.

methodsThis is an IRB-approved, HIPAA-compliant study. Informed consent was waived for this study. The electronic safety incident reporting system of our hospital was searched for the variables from April 2006 to September 2012. Incident classifications were diagnostic test orders, ID/documentation, safety/security/conduct, service coordination, surgery/procedure, line/tube, fall, medication/IV safety, employee general incident, environment/equipment, adverse drug reaction, skin/tissue and diagnosis/treatment.

resultsA total of 1918 incident reports occurred in the study period and 843,902 CT examinations were performed. The rate of safety incident was 0.22 % (1918/843,902). The highest incident rates were due to adverse drug reactions (652/843,902 = 0.077 %) followed by medication/IV safety (573/843,902 = 0.068 %) and diagnostic test orders (206/843,902 = 0.024 %). Overall 45 % of incidents (869/1918) caused no harm and did not affect the patient, 33 % (637/1918) caused no harm but affected the patient, 22 % (420/1918) caused temporary or minor harm/damage and less than 1 % (10/1918) caused permanent or major harm/damage or death.

conclusionOur study shows a total safety incident report rate of 0.22 % in CT. The most common incidents are adverse drug reaction, medication/IV safety and diagnostic test orders. KEY POINTS: • Total safety incident report rate in CT is 0.22 %. • Adverse drug reaction is the most common safety incident in CT. • Medication/IV safety is the second most common safety incident in CT.

Indexed as

Academic Medical CentersContrast MediaHumansRadiographic Image EnhancementRisk ManagementTomography, X-Ray ComputedContrast MediaCT incident reportingCT quality and safetyIncident reporting rateSafety incident reportingSafety incident reporting system

Identifiers

PMID26560719

DOI10.1007/s00330-015-4061-0

What OpenQuestion holds

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Registered trials

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.