Abstract:
RATIONALE AND OBJECTIVES:The aims of this study were to review the role of a quality information program (QUIP) as a semiautomated educational feedback mechanism and to review common errors in cross-sectional abdominal and pelvic studies as an initiative for continuing medical education and improving patient care. MATERIALS AND METHODS:Abdominal and pelvic errors identified by QUIP and cases collected from morbidity and mortality conferences were reviewed. Errors were classified and graded to levels of morbidity. RESULTS:There were 222 errors in 218 patients over 4 years in this study. One hundred thirteen (51%) were identified after the introduction of QUIP (January to December 2009). One hundred thirty-eight studies (61%) were read independently, while 84 (39%) were double-read. Sixty-five percent of errors (145 of 222) were false-negatives, of which 45 (31%) were "satisfaction-of-search" errors. There were 62 cognitive errors (28%), nine technical errors (4%), eight communication errors (4%), six ordering errors (3%), and five false-positives identified. Seventy-six percent of errors were identified on computed tomography (n = 168); fewer cases involved ultrasound (n = 20 [9%]) and magnetic resonance (n = 34 [15%]). Forty-one percent resulted in no changes to patient outcomes. Forty-percent caused minor patient morbidity, and 19% caused major patient morbidity, including three cases (1%) that likely contributed to patient death. CONCLUSIONS:Most abdominopelvic errors in this study were classified as false-negatives. Many can be attributed to satisfaction-of-search errors. Implementing a simple, semiautomated QUIP allows timely feedback regarding errors to radiologists. This may improve the quality of health care while allowing radiologists the opportunity to learn from each case they are involved in.
journal_name
Acad Radioljournal_title
Academic radiologyauthors
Kielar AZ,McInnes M,Quan M,O'Sullivan Jdoi
10.1016/j.acra.2011.06.012subject
Has Abstractpub_date
2011-11-01 00:00:00pages
1358-64issue
11eissn
1076-6332issn
1878-4046pii
S1076-6332(11)00339-4journal_volume
18pub_type
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journal_title:Academic radiology
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doi:10.1016/j.acra.2006.05.004
更新日期:2006-09-01 00:00:00
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doi:10.1016/j.acra.2004.07.017
更新日期:2004-11-01 00:00:00
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journal_title:Academic radiology
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更新日期:2018-07-01 00:00:00
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journal_title:Academic radiology
pub_type: 杂志文章,多中心研究
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更新日期:2008-09-01 00:00:00
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journal_title:Academic radiology
pub_type: 传,历史文章,杂志文章,评审
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