Pop quiz: What happened a year ago on September 6?

If you guessed Hurricane Irma landing in the Caribbean or Metallica’s epic live concert in Amsterdam, you would be correct. However, at BCPSLS Central Office we’re remembering a different kind of phenomenon: the launch of our new Medical Imaging report form!

While some may argue this isn’t quite as powerful as 185 miles per hour winds or your favourite band live in concert, we’ve seen some pretty impressive results. And when you consider the potential impact on patient safety in BC, your mind might just get blown.

We’re sharing news about reporting volumes and a summary dashboard available to medical imaging leaders across the province. We’ve also included a list of the kinds of safety events you can report using the new Medical Imaging form.

And we hope the pop quiz ignited your inner scholar, because there’s a test below that will really get your medical imaging wheels turning.

 

Increase in reporting

The new form was introduced last fall to support better reporting and learning from patient safety events involving medical imaging procedures. The form was the result of a collaboration of Lower Mainland Medical Imaging (LMMI), BCPSLS Central Office, and medical imaging representatives from across the province.

In our blog story detailing the 2017 launch, Elizabeth Jongedijk, Regional Manager, Quality & Process Improvement, Radiology, at Vancouver Coastal Health, expressed her hope to see an increase in the number of reports submitted. She predicted that the medical imaging-specific form would raise the profile of BCPSLS as a tool to improve safety culture and processes.

It looks like Elizabeth has been granted her wish, because medical imaging safety event reporting has quadrupled since the new form was launched.

“People love that medical imaging has its own form now,” says Elizabeth. “Some people wish the form was shorter, but each field is essential in order for us to get the kind of data we need to make improvements to patient care.”

 

Dashboard summary reports

Sharing the data has become a lot easier, as well. In July 2018, BCPSLS made a dashboard available to medical imaging leaders across the province. The dashboard offers a summary of reported events that can be used to guide quality and safety discussions and focus improvement efforts.

The medical imaging dashboard was designed with feedback from LMMI leaders and stakeholders. It displays incidents reported during the last twelve months plus the current month, in “real time” so it’s always up-to-date. Graphs show aggregate data around reporting volumes, near misses, harm, and phases of procedures when incidents occurred. The dashboard also highlights particular areas of interest, such as unnecessary exposure to radiation and incidents involving vascular access lines.

“It’s anticipated that dashboards will help spark conversations about quality improvement,” explains Trudy Pel Zaharik, Regional Quality Coordinator, LMMI. “For example, programs may choose to focus improvement efforts on what happens before exams, if this is trending on the dashboard. Guided by data in PSLS, improvements could be targeted to patient prep or to ensuring correct patient orders.”

 

 

What should you report?

Trudy has put together a list of examples of medical imaging events to report in BCPSLS using the new Medical Imaging report form. Can you think of any others? Feel free to submit a comment below!

1. Injuries resulting from a medical imaging procedure
2. Incorrectly ordered test or procedure
3. Incorrect body part, site, or side imaged
4. Incorrect patient imaged
5. Exam ordered for the incorrect patient
6. Inadequate patient preparation
7. Interstitial IV infusion affecting patient care
8. Equipment malfunction causing the patient to be reimaged
9. Incorrect data sent to PACS
10. Errors in communication of results
11. Issues with interfacility transfer of patients requiring a medical imaging procedure at another site
12. Issues with transfer and handover of patients to and from medical imaging

 

 

Test your knowledge

How solid is your understanding of how to report medical imaging events in BCPSLS? To help sharpen your skills, we’ve included the quiz that was developed for the September 2017 Go Live.

We’re delighted to announce that Leah Moran at Royal Columbian Hospital won the $50 gift card to Cactus Club in our prize draw for correctly answering the quiz last fall. Congratulations, Leah!

Which form would you use to report the following safety event scenarios? Scroll down for the correct answers.

 

1. The technologist used the wrong side-marker on the patient during the x-ray.

• Unsafe Behaviour
• Medical Imaging
• Laboratory
• This is not a reportable event

2. A patient was sent for ultrasound with an insulin infusion running. When the patient returned to the ward, the infusion was found to be clamped and no longer running.

• Medication
• Safety Hazard
• Medical Imaging
• This is not a reportable event

3. An x-ray was performed on the wrong patient.

• Medical Imaging
• Unsafe Behaviour
• Safety Hazard
• This is not a reportable event

4. A heavily sedated patient who required close monitoring was left in Medical Imaging without handover to staff.

• Medication
• Safety Hazard
• Medical Imaging
• This is not a reportable event

5. A patient arrived in Medical Imaging with an order for a cervical spine x-ray. After the test was completed, the Emergency Department telephoned and said that a lumbar spine x-ray was supposed to have been done instead.

• Unsafe Behaviour
• Medical Imaging
• Safety Hazard
• This is not a reportable event

6. A patient was sent for a CT scan. The patient stated that he had no allergies and was administered contrast dye. Soon after the infusion, the patient developed hives on his face and neck and complained of a scratchy throat. He was monitored and recovered.

• Medical Imaging
• Safety Hazard
• Adverse Drug Reaction
• Unsafe Behaviour

7. A patient walked unaccompanied to Medical Imaging from an outpatient clinic. She fainted and hit her head.

• Unsafe Behaviour
• Fall
• Medical Imaging
• Visitor Safety

 

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Answer key

1. Medical Imaging
2. Medication
3. Medical Imaging
4. Safety Hazard
5. Medical Imaging
6. Adverse Drug Reaction
7. Fall

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Looking ahead

The more medical imaging safety incidents reported, the more data we will have to learn from.

As the data are used to guide discussions and focus improvement efforts, we look forward to hearing about and celebrating initiatives aimed at reducing harm.

And, as always, your feedback is welcome. A number of improvements have been made to the Medical Imaging form since its Go Live and we continue to encourage stakeholders across the province to let us know how it’s working for them.

Congratulations to the medical imaging community in BC for making the new form such a success!