A Multi-observer Study of the Effect of Including Point-of-care Patient Photographs with Portable Radiography: A Means to Reduce Wrong-Patient Errors Público

Abstract

Hospital errors are the third leading cause of deaths in the United States. Within radiology, an important source of error is a wrong-patient error, wherein one patient's imaging study may be placed in another patient's folder in the Picture Archiving and Communication System. Despite the current technique for using dual-identifiers for patient identification, wrong-patient errors continue to occur. One potential solution is to include a patient's facial photograph with their respective radiograph. To test this, a prospective radiologist observer study with simulated wrong-patient errors was conducted in the 2012 American Board of Radiology's Oral Examination setting. Patient radiographs and photographs were obtained in two cardiothoracic intensive care units at Emory University, Atlanta GA. A total of 30 patients contributed 166 simultaneously obtained radiograph-photograph combinations. Eighty-seven radiologists with varied experience participated. Each radiologist interpreted a unique, randomly chosen set of 10 radiographic pairs with or without photographs and containing up to 10% simulated wrong-patient errors. Sensitivity for error detection and time for interpretation of each pair was measured. Patient photographs increased sensitivity for error detection from 29% (8/28) to 82% (23/28) (P < 0.001). The odds ratio for error detection with photographs was 11.5 (95% CI: 3.5, 44.9). Observer qualifications, demographics, training or practice subspecialty did not influence sensitivity. Interpretation time medians (range) without and with photographs were 52 (22-19) and 61 (17-140) seconds, respectively (P = 0.85). The results indicate the addition of patient photographs significantly increased the identification of wrong-patient errors and offers a potential means to increase patient safety. While the introduction of patient photographs does not appear to significantly increase the interpretation time, further examination of the impact of including patient photographs on radiology workflow is an important next step.

Table of Contents

INTRODUCTION................................................................................................................................................................... 1

BACKGROUND........................................................................................................................................................................ 3

METHODS................................................................................................................................................................................... 6

RESULTS................................................................................................................................................................................... 12

DISCUSSION............................................................................................................................................................................ 15

CONCLUSIONS..................................................................................................................................................................... 19

REFERENCES......................................................................................................................................................................... 20

TABLES AND FIGURES.................................................................................................................................................... 21

About this Master's Thesis

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School	Laney Graduate School
Department	Clinical Research Curriculum Program
Degree	MS
Submission	Master's Thesis
Language	English
Research Field	Engineering, Biomedical Health Sciences, Radiology
Palabra Clave	Radiology Observer Study Medical Errors
Committee Chair / Thesis Advisor	Tridandapani, Srini, Emory University
Committee Members	Bruce, Beau Benjamin, Emory University Manatunga, Amita, Emory University

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