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Published in: Pediatric Radiology 1/2018

01-01-2018 | Original Article

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

Authors: Camilo Jaimes, Diana J. Murcia, Karen Miguel, Cathryn DeFuria, Pallavi Sagar, Michael S. Gee

Published in: Pediatric Radiology | Issue 1/2018

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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.
Literature
1.
go back to reference 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 307:2400–2409CrossRefPubMed 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 307:2400–2409CrossRefPubMed
2.
go back to reference 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 13:1010–1017CrossRefPubMed 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 13:1010–1017CrossRefPubMed
3.
go back to reference 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 45:115–121CrossRefPubMed 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 45:115–121CrossRefPubMed
4.
go back to reference 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 7:593–602CrossRefPubMed 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 7:593–602CrossRefPubMed
5.
go back to reference 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 43:998–1007CrossRefPubMed 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 43:998–1007CrossRefPubMed
6.
7.
go back to reference 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 86:20120336CrossRefPubMedPubMedCentral 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 86:20120336CrossRefPubMedPubMedCentral
8.
go back to reference Jaimes C, Gee MS (2016) Strategies to minimize sedation in pediatric body magnetic resonance imaging. Pediatr Radiol 46:916–927CrossRefPubMed Jaimes C, Gee MS (2016) Strategies to minimize sedation in pediatric body magnetic resonance imaging. Pediatr Radiol 46:916–927CrossRefPubMed
9.
go back to reference Williams K, Thomson D, Seto I et al (2012) Standard 6: age groups for pediatric trials. Pediatrics 129:S153–S160CrossRefPubMed Williams K, Thomson D, Seto I et al (2012) Standard 6: age groups for pediatric trials. Pediatrics 129:S153–S160CrossRefPubMed
10.
go back to reference Brook OR, Kruskal JB, Eisenberg RL et al (2015) Root cause analysis: learning from adverse safety events. Radiographics 35:1655–1667CrossRefPubMed Brook OR, Kruskal JB, Eisenberg RL et al (2015) Root cause analysis: learning from adverse safety events. Radiographics 35:1655–1667CrossRefPubMed
11.
go back to reference 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 42:1339–1346CrossRefPubMed 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 42:1339–1346CrossRefPubMed
13.
go back to reference 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 189:1533–1538CrossRefPubMed 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 189:1533–1538CrossRefPubMed
14.
go back to reference Sanborn PA, Michna E, Zurakowski D et al (2005) Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 237:288–294CrossRefPubMed Sanborn PA, Michna E, Zurakowski D et al (2005) Adverse cardiovascular and respiratory events during sedation of pediatric patients for imaging examinations. Radiology 237:288–294CrossRefPubMed
15.
go back to reference 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 45:108–114CrossRefPubMed 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 45:108–114CrossRefPubMed
16.
go back to reference 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 164:554–560CrossRefPubMedPubMedCentral 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 164:554–560CrossRefPubMedPubMedCentral
17.
go back to reference Woods D, Thomas E, Holl J et al (2005) Adverse events and preventable adverse events in children. Pediatrics 115:155–160CrossRefPubMed Woods D, Thomas E, Holl J et al (2005) Adverse events and preventable adverse events in children. Pediatrics 115:155–160CrossRefPubMed
18.
go back to reference Kaushal R, Bates DW, Landrigan C et al (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120CrossRefPubMed Kaushal R, Bates DW, Landrigan C et al (2001) Medication errors and adverse drug events in pediatric inpatients. JAMA 285:2114–2120CrossRefPubMed
19.
go back to reference Vanderby SA, Babyn PS, Carter MW et al (2010) Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology 256:229–237CrossRefPubMed Vanderby SA, Babyn PS, Carter MW et al (2010) Effect of anesthesia and sedation on pediatric MR imaging patient flow. Radiology 256:229–237CrossRefPubMed
20.
go back to reference 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 1252:43–50CrossRefPubMedPubMedCentral 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 1252:43–50CrossRefPubMedPubMedCentral
21.
go back to reference Schultz SR, Watson RE Jr, Prescott SL et al (2011) Patient safety event reporting in a large radiology department. AJR Am J Roentgenol 197:684–688CrossRefPubMed Schultz SR, Watson RE Jr, Prescott SL et al (2011) Patient safety event reporting in a large radiology department. AJR Am J Roentgenol 197:684–688CrossRefPubMed
22.
go back to reference 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 30:1579–1585CrossRefPubMed 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 30:1579–1585CrossRefPubMed
23.
go back to reference 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, MD 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, MD
24.
go back to reference 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 12:594–598CrossRefPubMed 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 12:594–598CrossRefPubMed
25.
go back to reference Tisdall MD, Hess AT, Reuter M et al (2012) Volumetric navigators for prospective motion correction and selective reacquisition in neuroanatomical MRI. Magn Reson Med 68:389–399CrossRefPubMed Tisdall MD, Hess AT, Reuter M et al (2012) Volumetric navigators for prospective motion correction and selective reacquisition in neuroanatomical MRI. Magn Reson Med 68:389–399CrossRefPubMed
27.
go back to reference Glockner JF, Hu HH, Stanley DW et al (2005) Parallel MR imaging: a user's guide. Radiographics 25:1279–1297CrossRefPubMed Glockner JF, Hu HH, Stanley DW et al (2005) Parallel MR imaging: a user's guide. Radiographics 25:1279–1297CrossRefPubMed
28.
go back to reference Obele CC, Glielmi C, Ream J et al (2015) Simultaneous multislice accelerated free-breathing diffusion-weighted imaging of the liver at 3T. Abdom Imaging 40:2323–2330CrossRefPubMed Obele CC, Glielmi C, Ream J et al (2015) Simultaneous multislice accelerated free-breathing diffusion-weighted imaging of the liver at 3T. Abdom Imaging 40:2323–2330CrossRefPubMed
29.
30.
go back to reference Starmer AJ, Spector ND, Srivastava R et al (2014) Changes in medical errors after implementation of a handoff program. N Engl J Med 371:1803–1812CrossRefPubMed Starmer AJ, Spector ND, Srivastava R et al (2014) Changes in medical errors after implementation of a handoff program. N Engl J Med 371:1803–1812CrossRefPubMed
31.
go back to reference Starmer AJ, Spector ND, Srivastava R et al (2012) I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 129:201–204CrossRefPubMed Starmer AJ, Spector ND, Srivastava R et al (2012) I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 129:201–204CrossRefPubMed
32.
go back to reference 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 14:1080–1086CrossRefPubMed 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 14:1080–1086CrossRefPubMed
33.
go back to reference Mansouri M, Shaqdan KW, Aran S et al (2015) Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports. Emerg Radiol 22:623–630CrossRefPubMed Mansouri M, Shaqdan KW, Aran S et al (2015) Safety incident reporting in emergency radiology: analysis of 1717 safety incident reports. Emerg Radiol 22:623–630CrossRefPubMed
34.
go back to reference 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 203:620–626CrossRefPubMed 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 203:620–626CrossRefPubMed
Metadata
Title
Identification of quality improvement areas in pediatric MRI from analysis of patient safety reports
Authors
Camilo Jaimes
Diana J. Murcia
Karen Miguel
Cathryn DeFuria
Pallavi Sagar
Michael S. Gee
Publication date
01-01-2018
Publisher
Springer Berlin Heidelberg
Published in
Pediatric Radiology / Issue 1/2018
Print ISSN: 0301-0449
Electronic ISSN: 1432-1998
DOI
https://doi.org/10.1007/s00247-017-3989-4

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