Applying the Universal Protocol to
Improve Patient Safety
in Radiology Services
Theresa V. Arnold, D.P.M.
Senior Patient Safety Analyst
© 2011 Pennsylvania Patient Safety Authority
“Wrong” Events: Not Only in the OR
• Multiple factors
• Wrong patient
– Similarity of site,
procedure, and patient
names
• Wrong procedure
– Breakdowns in
communications and
teamwork
• Wrong side
• Wrong site
– Patient and procedure
factors
– Failed safety checks
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Archives of Surgery Study- 2010
• All wrong-patient events
involved errors in
communication
• “Non-surgical disciplines
equally contribute to patient
injuries related to wrong-site
procedures”
• Expand protocols to prevent
wrong events to include
nonsurgical specialties
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Wrong Events by Radiology Study
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PA-Patient Safety Reporting System Data
• Events reported in 2009
identified three main sources
of error:
– Ordering and scheduling errors
– Patient misidentification
– Inaccurate procedure verification
• Side or site
• Need for study
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Main Sources of Patient Harm
• Unnecessary radiation
− Higher the dose of
radiation at any one
time, the greater the
risk for long-term
damage
• Delay in diagnosis and
treatment
• Incorrect treatment
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Causes of Wrong-Site Procedures
• Acting on the basis of
misinformation
− Wrong information on the
schedule, order, or given by the
patient
• Having a misperception of
the patient’s situation
− Right/left confusion
− Patient symptomatology
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1. Ordering and Scheduling Inaccuracy
• Inaccurate order entry or
scheduling from:
– Hospital patient care areas
– Physician offices
– Radiology registration or
clerical personnel
– Technologist selecting wrong
study option
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1. Ordering and Scheduling Inaccuracies
• A patient arrived at the radiology front
desk for a scheduled appointment. The
patient handed the medical office
assistant her request and the assistant
logged her as arrived for a two-view chest
x-ray. While preparing to scan the
request, the assistant noticed that the
exam was for a chest CT scan and not a
chest x-ray. The patient had already been
taken into the x-ray room and the images
acquired.
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2. Patient Misidentification
• Patient identity not verified using
two identifiers
– Patient or a representative was not
included in the identification
process
• “What is your name and date of
birth?”
• Patients misidentified by using
– Room number
– Procedure or study
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2. Patient Misidentification
• Transport called to bring patient A to
radiology. Transport brought patient B with
patient A’s medical record. Technologist
verified the name on medical record and
asked patient if her name was patient A.
Patient responded “yes.” The exam was
performed. Nurse then called and informed
technologist that the wrong patient was
transported to the [radiology] department.
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3. Procedure Verification
• Lack of policies or procedures to verify
intended studies
– Clinical correlation not performed to support
need for study
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3. Procedure Verification
• Inadequate screening before imaging
study
– MRI, pregnancy, and renal function
– Current use of a contraindicated
medication (e.g., metformin)
• Order or prescription misinterpretation
– Illegibility of chart notes, orders, or
prescriptions (e.g., improper contrast
administration)
• Procedure duplication
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3. Procedure Verification
• A patient arrived for an upper external arterial
ultrasound exam. The technologist identified
the patient and began asking the patient
about her leg symptoms. The patient
described symptoms of the lower extremities,
which seemed appropriate for the exam. The
technologist was interrupted by phone calls
and, distracted, performed a lower extremity
exam without first verifying the physician’s
order. The error was discovered after the end
of the exam and the patient was
rescheduled.
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4. Side or Site Misidentification
• Site misidentification occurred
when:
– Technologists were distracted
– Technologists relied on the direction
and symptomatology of the patient
• order was not available
• order or physician’s prescription
referenced an alternate side or site
– Student technologists were
inadequately supervised.
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4. Side/site Misidentification
• The patient’s mother stated the child fell
on his left side and needed a left clavicle
x-ray. The child was upset and crying
during the procedure. The physician’s
office had ordered [the x-ray] for the right
clavicle. The patient returned for right
[clavicle] x-ray.
© 2011 Pennsylvania Patient Safety Authority
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Physician Office Protocols
• Lacked protocols to verify clinical information
before scheduling a study or procedure:
− Physician did not confirm orders before staff
scheduled procedure
– Two forms of patient identification were not used
– Incorrect radiologic study or site of study was
ordered by the physician without verifying accuracy
• Required additional scanning of the correct site
or performance of another study
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Physician Office
• A patient arrived for a scheduled MRI of
the cervical spine. The physician’s order
was for the thoracic spine. MRI of thoracic
spine was completed. The physician’s
office notified MRI when they received
results of incorrect test. Test was
scheduled correctly, but physician’s order
was incorrect.
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Physician Office
• Mammograms were commonly
ordered or scheduled inaccurately
− 60% improperly ordered
− 73% screening instead of diagnostic
− 17% diagnostic instead of screening
− 10% unspecified error
− 40% improperly scheduled
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Near Miss or “Good Catch” Events
• An order was placed by the intensive care unit for a
CT [computed tomography ] scan of the thoracic
spine. When the patient was brought down [to
radiology], the order was written for a cervical spine.
The patient was put on the table. The physician’s
office was called because the order did not specify
CT. The doctor stated he wanted plain x-rays of the
cervical spine. The patient was taken to the x-ray
[unit] for his films. The nursing unit was notified that
they placed the wrong order.
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Strategies to Improve Patient Safety
• Obtain leadership support
• Standardize policies and
procedures to reduce
variability
• Apply the principles of the
Universal Protocol
– Verification and reconciliation
– Site referencing
– Time-out
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Applying the Universal Protocol
• Patient consented to left L4/5 epidural and L4/5
facet injection. Surgeon marked left side
preoperatively. In the OR, the patient was placed
prone and fluoro was used to position the patient
and a time-out was done. All members agreed
with L4/5 level. X-ray tech preprogrammed
machine the day before and inadvertently typed
the level as L5/S1. This showed up on the fluoro
viewing screen during the procedure. After the
procedure, surgeon noted that the level injected
did not match OR paperwork and notified the
patient.
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Strategies to Improve Patient Safety
• Everyone is ACCOUNTABLE
– Review all available documents
o Verify that the requisition and the medical
record order or physician’s prescription are
consistent
– Verify orders that are unclear, illegible or
inconsistent with patient expectations
o Consult radiologist
– Implement “read back” to confirm verbal orders
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Strategies to Improve Patient Safety
• Ensure two unique patient
identifiers
– Involve two independent
technologists
– Use patient-specific identifiers
– Promote patient awareness of
identification protocols
– Assess staff competency with
compliance
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Visit the Authority’s Website
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Available Resources
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Questions
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