Diagnostic imaging in the ambulatory setting is influenced by a confluence of socio-technical factors that contribute to performance of inappropriate exams as well as delayed or missed exams, all leading to diagnostic failures. We assess factors contributing to diagnostic errors and develop and evaluate interventions to address these failures in diagnostic imaging.
Funded by the Agency for Healthcare Research and Quality (AHRQ), we identified several information sources that can further elucidate diagnostic imaging errors. These include an electronic safety reporting system (ESRS), an alert notification for critical result (ANCR) system, Picture Archiving and Communication System (PACS)-based quality assurance (QA) tool, an imaging peer-review system, and an imaging Computerized Physician Order Entry (CPOE) and scheduling system. These systems captured events that can potentially lead to patient harm. By addressing factors that contribute to diagnostic failures, our goal is to enhance diagnostic safety and quality.
Publications related to socio-technical factors and information sources relating to diagnostic imaging errors:
- Classifying Safety Events Related to Diagnostic Imaging From a Safety Reporting System Using a Human Factors Framework
- Assessing Information Sources to elucidate Diagnostic Process Errors in Radiologic Imaging – a Human Factors Framework
Specific initiatives that have been developed to address diagnostic examination errors include an initiative to enhance communication of radiologists’ follow-up recommendations in emergency department discharge instructions. More recently, development of a communication tool to enhance communication between radiologists and other providers and enable them to establish collaborative plans for managing patients has been developed.
- Adoption of a Closed-Loop Communication Tool to Establish and Execute a Collaborative Follow-Up Plan for Incidental Pulmonary Nodules
- Assessing Documentation of Critical Imaging Result Follow-up Recommendations in Emergency Department Discharge Instructions