Carrara, Marco (2020) A new complication registration system for errors in radiology: initial 5-year experience in a tertiary care radiology department. thesis, Medicine.
Full text available on request.Abstract
Errors or complications in radiology are one of the major causes leading to poor patient care. This paper describes and evaluates the initial 5-year experience with a new complication registration system for errors in radiology in the UMCG, a tertiary-care centre. The idea behind this paper is therefore to both analyse the new system but also assess the effect on patients’ care. This study reviewed all cases that were submitted to a new complication registration system of the UMCG between 2015-2019. Sixty-seven cases were included. In the group of diagnostic complications/errors, there were 21 perceptual errors and 13 cognitive errors. This 61.8% (21/34) perceptual error rate was not significantly different (P=0.297) from the 70% perceptual error rate known from previous literature. In the group of interventional complications (n=19), most cases (47.4% [9/19]) concerned symptomatic or major haemorrhage. In the group of organisational complications/errors (n=14), the leading incident type according to the International Classification System for Patient Safety was clinical process/procedure with wrong body part/side/site as subclassification (35.7% [5/14]). Harm severities were none (n=35), mild (n=10), moderate (n=10), severe (n=6), death (n=5), and unknown (n=1). Harm severity of interventional complications was significantly higher (P<0.05) than that of organisational complications, while there were no significant differences in harm severities between other groups of complications. It is feasible to implement the complication registration system for radiologic errors that was described in this study. Perceptual mistakes, haemorrhage, and procedures on the wrong body part/ side/site dominated in the categories of diagnostic, interventional, and organisational complications/ errors, respectively, and these should be the topic of vigilance in clinical practice and further research.
| Item Type: | Thesis (UNSPECIFIED) |
|---|---|
| Supervisor name: | Kwee, MD PhD, Thomas C. |
| Faculty: | Medical Sciences |
| Date Deposited: | 06 Sep 2023 13:02 |
| Last Modified: | 06 Sep 2023 13:02 |
| URI: | https://umcg.studenttheses.ub.rug.nl/id/eprint/3675 |
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