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Type: Journal article
Title: Learning from incident reports in the Australian medical imaging setting: handover and communication errors
Author: Hannaford, N.
Mandel, C.
Crock, C.
Buckley, K.
Magrabi, F.
Ong, M.
Allen, S.
Schultz, T.
Citation: British Journal of Radiology, 2013; 86(1022):20120336-1-20120336-11
Publisher: British Institute of Radiology
Issue Date: 2013
ISSN: 0007-1285
Department: Faculty of Health Sciences
Statement of
N Hannaford, C Mandel, C Crock, K Buckley, F Magrabi, M Ong, S Allen, and T Schultz
Abstract: Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n=298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion: The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings.
Keywords: Humans
Diagnostic Errors
Diagnostic Imaging
Transportation of Patients
Risk Assessment
Aged, 80 and over
Middle Aged
Child, Preschool
Medical Errors
Referral and Consultation
Young Adult
Delayed Diagnosis
Patient Safety
Patient Handoff
Rights: © 2013 The Authors
DOI: 10.1259/bjr.20120336
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