Kuvantamisen potilasturvallisuus:vaara-, haitta- ja läheltä piti -tilanteet Suomen kuvantamiskeskuksissa

Abstract There is a possibility of harm associated with all human activity. Adverse events in imaging are related to the radiation equipment’s, image interpretation and various other aspects of the imaging process. Adverse events in imaging occur infrequently compared to the number of examinations however the effect on the patient may be substantial. The purpose of this study was to form a vision of the harmful incidents related to imaging by analysing how frequently adverse events, harms and near misses occur in Finnish public and private health care imaging units. The research material consisted of statistics obtained from three different authorities. The data of the Radiation and Nuclear Safety Authority consisted of 293 reports of adverse events of radiological examinations and measures. The statistics of the Patient Insurance Center included 1054 injury claims made by patients. In addition, the third data consisted of 7287 claims made by healthcare personnel to the electronic patient safety incident reporting system. The highest incidence of unnecessary or excessive radiation occurred in computed tomography (CT) scans. Injury reports made by patients were mostly related to incorrect or delayed diagnosis. Of the adverse events reported by staff, 75% caused some degree of harm to the patient, and 25% were near misses. Supervisors rated the risks associated with the adverse event as low (47.7%), insignificant (35%), or tolerable (15.7%). Investigating imaging incidents is significant and useful. The information generated by the research can be utilized in the systematic reduction and prevention of incidents related to various imaging processes. The research will increase the national development of patient safety in Finnish healthcare in the future.Tiivistelmä Kaikessa inhimillisessä toiminnassa on mahdollisuus tapahtua vahinko. Lääkinnällisen kuvantamisen vaaratapahtumat liittyvät tutkimuksessa käytettävään säteilyyn, laitteisiin kuvantulkintaan ja muihin kuvantamisprosessin vaiheisiin. Kuvantamisen vaaratapahtumia on suhteellisen vähän (alle 4 %), mutta haitan vaikutus saattaa olla potilaalle suuri. Tämän tutkimuksen tarkoituksena oli muodostaa näkemys kuvantamiseen liittyvistä vaaratapahtumista analysoimalla Suomen julkisen ja yksityisen terveydenhoidon kuvantamisyksiköiden vaara-, haitta- ja läheltä piti -tapahtumia. Tutkimuksen aineisto koostui säteilyturvakeskuksen (293 kpl) ja potilasvakuutuskeskuksen (1054 kpl) aineistosta sekä asiakas- ja potilasturvallisuuskeskuksen hallinnoimista terveydenhuoltohenkilökunnan sosiaali- ja terveydenhuollon vaaratapahtumajärjestelmään tekemistä ilmoituksista (7287 kpl). Tutkimuksen perusteella tietokonetomografiatutkimuksissa (TT) tapahtui useimmin turhaan tai liialliseen säteilyyn liittyviä poikkeavia tilanteita. Potilaiden tekemät vahinkoilmoitukset liittyivät virheelliseen tai viivästyneeseen diagnostiikkaan. Henkilökunnan ilmoittamista vaaratapahtumista 75 % aiheutti potilaalle jonkin asteisen haitan ja 25 % oli läheltä piti -tilanteita. Esimiehet arvioivat haittatapahtumaan liittyneet riskit vähäisiksi (47,7 %), merkityksettömiksi (35 %) tai kohtalaisiksi (15,7 %). Tutkimus osoitti, että kuvantamisen potilasturvallisuuteen liittyvien vaaratilanteiden analysointi on tarpeellista. Tutkimuksen tuottamaa tietoa voidaan hyödyntää kuvantamisen eri prosesseihin liittyvien vaaratapahtumien suunnitelmallisessa vähentämisessä ja ennaltaehkäisyssä. Tutkimus lisää Suomen terveydenhuollon potilasturvallisuuden kansallista kehitystä tulevaisuudessa

Investigating errors in medical imaging:medical malpractice cases in Finland

Abstract Objective: The objectives of the study were to survey patient injury claims concerning medical imaging in Finland in 1991–2017, and to investigate the nature of the incidents, the number of claims, the reasons for the claims, and the decisions made concerning the claims. Materials and methods: The research material consisted of patient claims concerning imaging, sent to the Finnish Patient Insurance Centre (PVK). The data contained information on injury dates, the examination code, the decision code, the description of the injury, and the medical grounds for decisions. Results: The number of claims included in the study was 1054, and the average number per year was 87. The most common cause was delayed diagnosis (404 claims, 38.3%). Most of the claims concerned mammography (314, 29.8%), radiography (170, 16.1%), and MRI (162, 15.4%). According to the decisions made by the PVK, there were no delays in 54.6% of the examinations for which claims were made. About 30% of all patient claims received compensation, the most typical reason being medical malpractice (27.7%), followed by excessive injuries and injuries caused by infections, accidents and equipment (2.7%). Conclusion: Patient injury in imaging examinations and interventions cannot be completely prevented. However, injury data are an important source of information for health care. By analysing claims, we can prevent harm, increase the quality of care, and improve patient safety in medical imaging

Detecting patient safety errors by characterizing incidents reported by medical imaging staff

Abstract The objectives of the study were to characterize events related to patient safety reported by medical imaging personnel in Finland in 2007–2017, the number and quality of reported injuries, the risk assessment, and the planned improvement of operations. The information was collected from a healthcare patient safety incident register system. The data contained information on the nature of the patient safety errors, harms and near-misses in medical imaging, the factors that lead to the events, the consequences for the patient, the level of risks, and future measures. The number of patient safety incident reports included in the study was 7,287. Of the incident reports, 75% concerned injuries to patients and 25% were near-misses. The most common consequence of adverse events and near-misses were minor harm (37.2%) related to contrast agent, or no harm (27.9%) related to equipment malfunction. Supervisors estimated the risks as low (47.7%) e.g., data management, insignificant (35%) e.g., verbal communication or moderate (15.7%) e.g., the use of contrast agent. The most common suggestion for learning from the incident was discussing it with the staff (58.1%), improving operations (5.7%) and submitting it to a higher authority (5.4%). Improving patient safety requires timely, accurate and clear reporting of various patient safety incidents. Based on incident reports, supervisors can provide feedback to staff, develop plans to prevent accidents, and monitor the impact of measures taken. Information on the development of occupational safety should be disseminated to all healthcare professionals so that the same mistakes are not repeated