Identifying radiology patient safety issues with health information technology by a retrospective analysis of 4,828 radiology safety incidents

Purpose: To identify and analyse the types of issues, contributing factors and their consequences associated with health information technology (HIT) from two patient safety incident reporting databases containing 4,828 incidents from radiology departments. Methods and materials: Analysis of 4,828 radiology safety incidents reported from June 2009 to March 2016 was undertaken. HIT related incidents were identified using a series of search terms, including 101 keywords. A clinical interest group was formed to assign keywords for identifying HIT related incidents. All identified incidents were cross‐checked to discern if they were HIT related or not using the definition used by the Agency for Healthcare Research and Quality (AHRQ) Common Formats in the United States as adopted by The Joint Commission (1). All identified HIT related incidents were further reviewed using a classification system developed by Magrabi et al. for problems associated with HIT (2). Results: Of all incidents, 1544 contained selected keywords. In total, 416 HIT related incidents were identified from the two databases using the AHRQ common formats classification. Since each incident can be categorised into more than one issues, in total, 622 issues identified. Of these issues, 36% (n = 222) involved use or human errors, 64% (n = 400) and involved machine or technical errors. Of 416 incidents, 31% (n = 128) described potential and actual harm to patients, including deaths (n = 4); 33% (n = 136) had arrested or interrupted sequence of near misses; 28% (n = 115) constituted noticeable consequences but no patient harm; 5% (n = 22) comprised hazardous events or circumstances; and 4% (n = 15) had no noticeable consequences. Contributing factors were identified for only 5% (n = 20) due to the limitations of the incident reporting system. ‘Information governance’ and integration with workflow’ were the most frequent contributing factors. Conclusion: Our study confirms that HIT does create hazardous circumstances in radiology and can lead to serious consequences, including death to patients. The results reinforce the common issues such as use error and machine error, arising from HIT implementation that may potentially affect multiple patients and clinicians, including on a larger scale, causing harm to radiology practice. Hence, this suggests that addressing them should be a high priority for all major HIT implementations.