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Clarifying radiology’s role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital



Common cause analysis of hospital safety events that involve radiology can identify opportunities to improve quality of care and patient safety.


To study the most frequent system failures as well as key activities and processes identified in safety events in an academic children’s hospital that underwent root cause analysis and in which radiology was determined to play a contributing role.

Materials and methods

All safety events involving diagnostic or interventional radiology from April 2013 to November 2018, for which the hospital patient safety department conducted root cause analysis, were retrospectively analyzed. Pareto charts were constructed to identify the most frequent modalities, system failure modes, key processes and key activities.


In 19 safety events, 64 sequential interactions were attributed to the radiology department by the patient safety department. Five of these safety events were secondary to diagnostic errors. Interventional radiology, radiography and diagnostic fluoroscopy accounted for 89.5% of the modalities in these safety events. Culture and process accounted for 55% of the system failure modes. The three most common key processes involved in these sequential interactions were diagnostic (39.1%) and procedural services (25%), followed by coordinating care and services (18.8%). The two most common key activities were interpreting/analyzing (21.9%) and coordinating activities (15.6%).


Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children’s hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology’s direct and indirect contributions to patient harm.

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  1. 1.

    Lyren A, Brilli RJ, Zieker K et al (2017) Children’s hospitals’ solutions for patient safety collaborative impact on hospital-acquired harm. Pediatrics 140.

  2. 2.

    Lyren A, Coffey M, Shepherd M et al (2018) We will not compete on safety: how children's hospitals have come together to hasten harm reduction. Jt Comm J Qual Patient Saf 44:377–388

    Google Scholar 

  3. 3.

    Lyren A, Dawson A, Purcell D et al (2019) Developing evidence for new patient safety bundles through multihospital collaboration. J Patient Saf.

  4. 4.

    Throop C, Stockmeier C (2011) SEC & SSER Patient safety measurement system for healthcare, revision 2. Virginia Beach, VA: Healthcare Performance Improvement (HPI) white paper series

  5. 5.

    McClead RE, Brady M (2016) Sentinel events/patient safety events. Pediatr Rev 37:448–450

    Article  Google Scholar 

  6. 6.

    Teets J, Czekalinski S, Teman S (2015) Forging together without competition: embedding culture principles using cause analysis. Accessed 12 Feb 2020

  7. 7.

    Vincent C, Carthey J, Macrae C, Amalberti R (2017) Safety analysis over time: seven major changes to adverse event investigation. Implement Sci 12:151

    Article  Google Scholar 

  8. 8.

    Trbovich P, Shojania KG (2017) Root-cause analysis: swatting at mosquitoes versus draining the swamp. BMJ Qual Saf 26:350–353

    Google Scholar 

  9. 9.

    Marx D (2019) Patient safety and the just culture. Obstet Gynecol Clin N Am 46:239–245

    Article  Google Scholar 

  10. 10.

    Larson DB, Kruskal JB, Krecke KN, Donnelly LF (2015) Key concepts of patient safety in radiology. Radiographics 35:1677–1693

    Article  Google Scholar 

  11. 11.

    Choksi VR, Marn C, Piotrowski MM et al (2005) Illustrating the root-cause-analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging. J Am Coll Radiol 2:768–776

    Article  Google Scholar 

  12. 12.

    Brook OR, Kruskal JB, Eisenberg RL, Larson DB (2015) Root cause analysis: learning from adverse safety events. Radiographics 35:1655–1667

    Article  Google Scholar 

  13. 13.

    Morse RB, Pollack MM (2012) Root cause analyses performed in a children's hospital: events, action plan strength, and implementation rates. J Healthc Qual 34:55–61

    Article  Google Scholar 

  14. 14.

    Charles R, Hood B, Derosier JM et al (2016) How to perform a root cause analysis for workup and future prevention of medical errors: a review. Patient Saf Surg 10:20

    Article  Google Scholar 

  15. 15.

    Kung JW, Brook OR, Eisenberg RL, Slanetz PJ (2016) How-I-do-it: teaching root cause analysis. Acad Radiol 23:881–884

    Article  Google Scholar 

  16. 16.

    Kudla AU, Brook OR (2018) Quality and efficiency improvement tools for every radiologist. Acad Radiol 25:757–766

    Article  Google Scholar 

  17. 17.

    Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S (2012) Preventing wrong site, procedure, and patient events using a common cause analysis. Am J Med Qual 27:21–29

    Article  Google Scholar 

  18. 18.

    Browne AM, Mullen R, Teets J et al (2008) Common cause analysis: focus on institutional change. In: Henriksen K, Battles JB, Keyes MA, Grady ML (eds) Advances in patient safety: new directions and alternatives approaches, vol 1. Rockville, Agency for Healthcare Research and Quality

    Google Scholar 

  19. 19.

    Muething SE, Goudie A, Schoettker PJ et al (2012) Quality improvement initiative to reduce serious safety events and improve patient safety culture. Pediatrics 130:e423–e431

    Article  Google Scholar 

  20. 20.

    Flug JA, Ponce LM, Osborn HH, Jokerst CE (2018) Never events in radiology and strategies to reduce preventable serious adverse events. Radiographics 38:1823–1832

    Article  Google Scholar 

  21. 21.

    Donnelly LF, Palangyo T, Bargmann-Losche J et al (2019) Creating a defined process to improve the timeliness of serious safety event determination and root cause analysis. Pediatr Qual Saf 4:e200

    Article  Google Scholar 

  22. 22.

    Snyder EJ, Zhang W, Jasmin KC et al (2018) Gauging potential risk for patients in pediatric radiology by review of over 2,000 incident reports. Pediatr Radiol 48:1867–1874

    Article  Google Scholar 

  23. 23.

    Lee CS, Nagy PG, Weaver SJ, Newman-Toker DE (2013) Cognitive and system factors contributing to diagnostic errors in radiology. AJR Am J Roentgenol 201:611–617

    Article  Google Scholar 

  24. 24.

    Kim YW, Mansfield LT (2014) Fool me twice: delayed diagnoses in radiology with emphasis on perpetuated errors. AJR Am J Roentgenol 202:465–470

    Article  Google Scholar 

  25. 25.

    Bruno MA, Walker EA, Abujudeh HH (2015) Understanding and confronting our mistakes: the epidemiology of error in radiology and strategies for error reduction. Radiographics 35:1668–1676

    Article  Google Scholar 

  26. 26.

    Busby LP, Courtier JL, Glastonbury CM (2018) Bias in radiology: the how and why of misses and misinterpretations. Radiographics 38:236–247

    Article  Google Scholar 

  27. 27.

    Itri JN, Patel SH (2018) Heuristics and cognitive error in medical imaging. AJR Am J Roentgenol 210:1097–1105

    Article  Google Scholar 

  28. 28.

    Itri JN, Tappouni RR, McEachern RO et al (2018) Fundamentals of diagnostic error in imaging. Radiographics 38:1845–1865

    Article  Google Scholar 

  29. 29.

    Taylor GA, Voss SD, Melvin PR, Graham DA (2011) Diagnostic errors in pediatric radiology. Pediatr Radiol 41:327–334

    Article  Google Scholar 

  30. 30.

    Donnelly LF, Dickerson JM, Goodfriend MA, Muething SE (2010) Improving patient safety in radiology. AJR Am J Roentgenol 194:1183–1187

    Article  Google Scholar 

  31. 31.

    Donnelly LF, Dickerson JM, Goodfriend MA, Muething SE (2009) Improving patient safety: effects of a safety program on performance and culture in a department of radiology. AJR Am J Roentgenol 193:165–171

    Article  Google Scholar 

  32. 32.

    Sammer MBK, Sammer MD, Donnelly LF (2019) Review of learning opportunity rates: correlation with radiologist assignment, patient type and exam priority. Pediatr Radiol 49:1269–1275

    Article  Google Scholar 

  33. 33.

    Kellogg KM, Hettinger Z, Shah M et al (2017) Our current approach to root cause analysis: is it contributing to our failure to improve patient safety? BMJ Qual Saf 26:381–387

    Google Scholar 

  34. 34.

    Braithwaite J, Westbrook MT, Mallock NA et al (2006) Experiences of health professionals who conducted root cause analyses after undergoing a safety improvement programme. Qual Saf Health Care 15:393–399

    Article  Google Scholar 

  35. 35.

    Wu AW, Lipshutz AKM, Pronovost PJ (2008) Effectiveness and efficiency of root cause analysis in medicine. JAMA 299:685–687

    CAS  Article  Google Scholar 

  36. 36.

    Wallace LM, Spurgeon P, Adams S et al (2009) Survey evaluation of the National Patient Safety Agency's root cause analysis training programme in England and Wales: knowledge, beliefs and reported practices. Qual Saf Health Care 18:288–291

    CAS  Article  Google Scholar 

  37. 37.

    van der Starre C, van Dijk M, van den Bos A, Tibboel D (2014) Paediatric critical incident analysis: lessons learnt on analysis, recommendations and implementation. Eur J Pediatr 173:1449–1457

    Article  Google Scholar 

  38. 38.

    Macrae C (2016) The problem with incident reporting. BMJ Qual Saf 25:71–75

    Article  Google Scholar 

  39. 39.

    Peerally MF, Carr S, Waring J, Dixon-Woods M (2017) The problem with root cause analysis. BMJ Qual Saf 26:417–422

    Google Scholar 

  40. 40.

    Francois P, Lecoanet A, Caporossi A et al (2018) Experience feedback committees: a way of implementing a root cause analysis practice in hospital medical departments. PLoS One 13:e0201067

    Article  Google Scholar 

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Correspondence to Hedieh Khalatbari.

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HPI Press Ganey Taxonomy of Individual Failure Modes. Used with permission (PDF 25 kb)


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Khalatbari, H., Menashe, S.J., Otto, R.K. et al. Clarifying radiology’s role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital. Pediatr Radiol 50, 1409–1420 (2020).

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  • Children
  • Common cause analysis
  • Error prevention
  • Improvement
  • Pediatric radiology
  • Quality and safety
  • Root cause analysis
  • Safety events