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Managing an Acute Adverse Event in a Radiology Department¹

¹ From the Department of Radiology, Beth Israel Deaconess Medical Center, 1 Deaconess Rd, West Campus 302B, Boston, MA 02215 (J.B.K., B.S., S.W.A., R.L.E.); and Hadassah Hebrew University Medical Center, Jerusalem, Israel (J.S.). Recipient of an Excellence in Design award for an education exhibit at the 2007 RSNA Annual Meeting. Received March 24, 2008; revision requested April 23 and received May 5; accepted May 7. J.S. received a research grant from Koninklijke Philips Electronics NV and is a consultant with Carestream Health (Algotec Systems) and ActiViews; all remaining authors have no financial relationships to disclose. Address correspondence to J.B.K. (e-mail: jkruskal{at}bidmc.harvard.edu).

Many local and national regulatory organizations require that all serious adverse events be promptly investigated, managed, and reported, with the first goal being to institute actions to prevent or minimize the occurrence of similar events. However, the tools and processes necessary for effective incident review and management have been developed largely by industrial organizations, and radiologists may not be familiar with such processes. Data analysis requires a root cause analysis to identify all possible active and latent contributors to the event, as well as the use of algorithms to determine the degree of responsibility when human error is implicated. Acceptable corrective actions that are reasonable, achievable, and measurable should be instituted. These changes should be monitored according to defined timelines by a designated person. In some cases, additional training or even remediation may be required. Subsequently, the focus should be on actively managing and improving error detection and reporting systems, as well as on seeking strategies for minimizing the occurrence of preventable errors.

© RSNA, 2008