Advertisement

Pediatric Radiology

, Volume 48, Issue 1, pp 66–73 | Cite as

Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports

  • Camilo Jaimes
  • Diana J. Murcia
  • Karen Miguel
  • Cathryn DeFuria
  • Pallavi Sagar
  • Michael S. Gee
Original Article

Abstract

Background

Analysis of safety reports has been utilized to guide practice improvement efforts in adult magnetic resonance imaging (MRI). Data specific to pediatric MRI could help target areas of improvement in this population.

Objective

To estimate the incidence of safety reports in pediatric MRI and to determine associated risk factors.

Materials and methods

In a retrospective HIPAA-compliant, institutional review board-approved study, a single-institution Radiology Information System was queried to identify MRI studies performed in pediatric patients (0–18 years old) from 1/1/2010 to 12/31/2015. The safety report database was queried for events matching the same demographic and dates. Data on patient age, gender, location (inpatient, outpatient, emergency room [ER]), and the use of sedation/general anesthesia were recorded. Safety reports were grouped into categories based on the cause and their severity. Descriptive statistics were used to summarize continuous variables. Chi-square analyses were performed for univariate determination of statistical significance of variables associated with safety report rates. A multivariate logistic regression was used to control for possible confounding effects.

Results

A total of 16,749 pediatric MRI studies and 88 safety reports were analyzed, yielding a rate of 0.52%. There were significant differences in the rate of safety reports between patients younger than 6 years (0.89%) and those older (0.41%) (P<0.01), sedated (0.8%) and awake children (0.45%) (P<0.01), and inpatients (1.1%) and outpatients (0.4%) (P<0.01). The use of sedation/general anesthesia is an independent risk factor for a safety report (P=0.02). The most common causes for safety reports were service coordination (34%), drug reactions (19%), and diagnostic test and ordering errors (11%).

Conclusion

The overall rate of safety reports in pediatric MRI is 0.52%. Interventions should focus on vulnerable populations, such as younger patients, those requiring sedation, and those in need of acute medical attention.

Keywords

Children Magnetic resonance imaging Quality improvement Safety Safety report 

Notes

Compliance with ethical standards

Conflicts of interest

None.

References

  1. 1.
    Smith-Bindman R, Miglioretti DL, Johnson E et al (2012) Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996-2010. JAMA 307:2400–2409CrossRefPubMedGoogle Scholar
  2. 2.
    Fernandes K, Levin TL, Miller T et al (2016) Evaluating an Image Gently and Image Wisely campaign in a multihospital health care system. J Am Coll Radiol 13:1010–1017CrossRefPubMedGoogle Scholar
  3. 3.
    Harvey HB, Hassanzadeh E, Aran S et al (2016) Key performance indicators in radiology: You can't manage what you can't measure. Curr Probl Diagn Radiol 45:115–121CrossRefPubMedGoogle Scholar
  4. 4.
    Jones DN, Thomas MJ, Mandel CJ et al (2010) Where failures occur in the imaging care cycle: lessons from the radiology events register. J Am Coll Radiol 7:593–602CrossRefPubMedGoogle Scholar
  5. 5.
    Mansouri M, Aran S, Harvey HB et al (2016) Rates of safety incident reporting in MRI in a large academic medical center. J Magn Reson Imaging 43:998–1007CrossRefPubMedGoogle Scholar
  6. 6.
    Cooper JB, Newbower RS, Long CD et al (2002) Preventable anesthesia mishaps: a study of human factors. 1978. Qual Saf Health Care 11:277–282CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Hannaford N, Mandel C, Crock C et al (2013) Learning from incident reports in the Australian medical imaging setting: handover and communication errors. Br J Radiol 86:20120336CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Jaimes C, Gee MS (2016) Strategies to minimize sedation in pediatric body magnetic resonance imaging. Pediatr Radiol 46:916–927CrossRefPubMedGoogle Scholar
  9. 9.
    Williams K, Thomson D, Seto I et al (2012) Standard 6: age groups for pediatric trials. Pediatrics 129:S153–S160CrossRefPubMedGoogle Scholar
  10. 10.
    Brook OR, Kruskal JB, Eisenberg RL et al (2015) Root cause analysis: learning from adverse safety events. Radiographics 35:1655–1667CrossRefPubMedGoogle Scholar
  11. 11.
    Rangamani S, Varghese J, Li L et al (2012) Safety of cardiac magnetic resonance and contrast angiography for neonates and small infants: a 10-year single-institution experience. Pediatr Radiol 42:1339–1346CrossRefPubMedGoogle Scholar
  12. 12.
    Plaisier A, Raets MM, van der Starre C et al (2012) Safety of routine early MRI in preterm infants. Pediatr Radiol 42:1205–1211CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Dillman JR, Ellis JH, Cohan RH et al (2007) Frequency and severity of acute allergic-like reactions to gadolinium-containing i.v. contrast media in children and adults. AJR Am J Roentgenol 189:1533–1538CrossRefPubMedGoogle Scholar
  14. 14.
    Sanborn PA, Michna E, Zurakowski D et al (2005) Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 237:288–294CrossRefPubMedGoogle Scholar
  15. 15.
    Delgado J, Toro R, Rascovsky S et al (2015) Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol 45:108–114CrossRefPubMedGoogle Scholar
  16. 16.
    Kiringoda R, Thurm AE, Hirschtritt ME et al (2010) Risks of propofol sedation/anesthesia for imaging studies in pediatric research: eight years of experience in a clinical research center. Arch Pediatr Adolesc Med 164:554–560CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Woods D, Thomas E, Holl J et al (2005) Adverse events and preventable adverse events in children. Pediatrics 115:155–160CrossRefPubMedGoogle Scholar
  18. 18.
    Kaushal R, Bates DW, Landrigan C et al (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120CrossRefPubMedGoogle Scholar
  19. 19.
    Vanderby SA, Babyn PS, Carter MW et al (2010) Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology 256:229–237CrossRefPubMedGoogle Scholar
  20. 20.
    Raschle N, Zuk J, Ortiz-Mantilla S et al (2012) Pediatric neuroimaging in early childhood and infancy: challenges and practical guidelines. Ann N Y Acad Sci 1252:43–50CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Schultz SR, Watson RE Jr, Prescott SL et al (2011) Patient safety event reporting in a large radiology department. AJR Am J Roentgenol 197:684–688CrossRefPubMedGoogle Scholar
  22. 22.
    Beckmann U, Gillies DM, Berenholtz SM et al (2004) Incidents relating to the intra-hospital transfer of critically ill patients. An analysis of the reports submitted to the Australian Incident Monitoring Study in Intensive Care. Intensive Care Med 30:1579–1585CrossRefPubMedGoogle Scholar
  23. 23.
    Sorra J, United States Agency for Healthcare Research and Quality, Westat Inc. (2007) Hospital survey on patient safety culture: 2007 comparative database report. Agency for Healthcare Research and Quality, Rockville, MDGoogle Scholar
  24. 24.
    Durand DJ, Young M, Nagy P et al (2015) Mandatory child life consultation and its impact on pediatric MRI workflow in an academic medical center. J Am Coll Radiol 12:594–598CrossRefPubMedGoogle Scholar
  25. 25.
    Tisdall MD, Hess AT, Reuter M et al (2012) Volumetric navigators for prospective motion correction and selective reacquisition in neuroanatomical MRI. Magn Reson Med 68:389–399CrossRefPubMedGoogle Scholar
  26. 26.
    Vasanawala SS, Alley MT, Hargreaves BA et al (2010) Improved pediatric MR imaging with compressed sensing. Radiology 256:607–616CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Glockner JF, Hu HH, Stanley DW et al (2005) Parallel MR imaging: a user's guide. Radiographics 25:1279–1297CrossRefPubMedGoogle Scholar
  28. 28.
    Obele CC, Glielmi C, Ream J et al (2015) Simultaneous multislice accelerated free-breathing diffusion-weighted imaging of the liver at 3T. Abdom Imaging 40:2323–2330CrossRefPubMedGoogle Scholar
  29. 29.
    Keil B, Alagappan V, Mareyam A et al (2011) Size-optimized 32-channel brain arrays for 3 T pediatric imaging. Magn Reson Med 66:1777–1787CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Starmer AJ, Spector ND, Srivastava R et al (2014) Changes in medical errors after implementation of a handoff program. N Engl J Med 371:1803–1812CrossRefPubMedGoogle Scholar
  31. 31.
    Starmer AJ, Spector ND, Srivastava R et al (2012) I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 129:201–204CrossRefPubMedGoogle Scholar
  32. 32.
    Goldberg-Stein S, Frigini LA, Long S et al (2017) ACR RADPEER committee white paper with 2016 updates: Revised scoring system, new classifications, self-review, and subspecialized Reports. J Am Coll Radiol 14:1080–1086CrossRefPubMedGoogle Scholar
  33. 33.
    Mansouri M, Shaqdan KW, Aran S et al (2015) Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports. Emerg Radiol 22:623–630CrossRefPubMedGoogle Scholar
  34. 34.
    Abujudeh HH, Aran S, Daftari Besheli L et al (2014) Outpatient falls prevention program outcome: an increase, a plateau, and a decrease in incident reports. AJR Am J Roentgenol 203:620–626CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  1. 1.Division of Neuroradiology, Department of RadiologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Division of Abdominal Imaging, Department of RadiologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  3. 3.Quality and Safety Office, Department of RadiologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  4. 4.Division of Pediatric Imaging, Department of RadiologyMassachusetts General Hospital for Children, Harvard Medical SchoolBostonUSA

Personalised recommendations