A protocol developed by radiologists at the Santa Clara Valley Medical Center reduced CT misadministration at the Santa Clara Valley Medical Center from 18 instances in 60,999 studies to zero in 36,608 in just 10 months. Misadministration includes, but is not limited to, imaging the wrong patient or body part without a physician's order or repeated imaging of a patient without a physician's order.
The best practices protocol includes several levels of assessment, including reverification checklists, workflow clarification, and individual accountability.
"CT misadministration is an important and actionable quality issue, particularly in light of growing public concern about radiation exposure," said Patrick Do, MD. "Our quality improvement analysis significantly reduced the rate of misadministration and potentially brings great benefits to patients, hospitals, and the public."
The study was featured in an electronic exhibit at the ARRS 2015 Annual Meeting in Toronto.
Abstract
Efficacy, Education, Administration, Informatics
E5319. CT Misadministration Reduction Program
Do P, Ma M, Phan P. Santa Clara Valley Medical Center, San Jose, CA
Objective: CT misadministration is defined as inappropriate administration of CT radiation to a patient (e.g., imaging the wrong patient or body part without a physician's order or repeated imaging of the patient without a physician's order). Per Section 115113 of the California Health and Safety Code, CT misadministration is a reportable event if dosages exceed 0.05 Sv or 5 rem effective dose equivalent, 0.5 Sv (50 rem) to an organ or tissue, or 0.5 Sv (50 rem) shallow dose equivalent to the skin. This legislation was enacted in January 2011 and serves as a starting point for quality improvement within radiology departments. There are many reasons why CT misadministration may occur, from patient-related issues and human performance problems to poor information flow and inadequate policies and procedures. These errors could be minimized with quality improvement analysis and subsequent creation of preventative systems. Reduction of CT misadministration is an important and actionable quality improvement process, with benefits to patients, hospital staff and administrators, and the public, especially in light of recent growing anxiety over radiation exposure. The purpose of this project is to improve quality as measured by the rate of CT misadministration. We aim to implement a system of quality improvement that will allow us to analyze factors contributing to error so that we can develop and apply a set of best practices.
Materials and Methods: A Plan Do Study Act cycle was initiated as the framework for quality improvement and a fishbone diagram was created to identify sources of error. A new best practices protocol was developed in collaboration with the CT technologists, involving reverification checklists and workflow clarification. Individual accountability was also emphasized by implementing concepts of just culture. The rate of CT misadministration was then assessed.
Results: Our quality improvement project resulted in a statistically significant decrease (?2 = 3.72, df = 1, p = 0.0269) in the incidence of CT misadministration. The incidence of CT misadministration decreased from 18 in 60,999 studies during the 16 months prior to our quality improvement project to 0 in 12,608 studies during the 6 months after its implementation.
Conclusion: A system of quality improvement provides a framework for identifying and acting upon areas of improvement within the workplace. We utilized such a framework to significantly decrease CT misadministration in our radiology department.