Most Vulnerable Steps for Communication Errors in Radiology

Radiologists’ errors in communication can have a direct impact on patient care.

Over one-third of communication errors that take place in a radiology department have a direct impact on patient care, and more than half have a potential impact, according to a study published in the American Journal of Roentgenology.

Researchers from the Beth Israel Deaconess Medical Center in Boston, MA, performed a study to determine the impact of communication errors on patient care, customer satisfaction, and work-flow efficiency and to identify opportunities for quality improvement.

The researchers found 380 of 422 cases of communication errors gathered from the quality assurance database at their facility between August 1, 2004 and December 31, 2014, which fit their criteria. The cases were analyzed for where in the imaging process the errors occurred, such as during ordering, scheduling, examination performance, study interpretation, or communication of the results. The impact on patient care was then graded on a five-point scale: none (0) to catastrophic (4).

The most common step where errors occurred was during communication of the results:

Step where error occurredNumber of patients affected
Ordering53 patients (13.9%)
Scheduling18 patients (4.7%)
Examination performance114 patients (30.0%)
Study interpretation14 patients (3.7%)
Result communication181  patients (47.6%)

There was no statistically significant difference in impact severity between errors that occurred during result communication and those that occurred at other times, the researchers noted.  According to the researchers, patient care was impacted in 144 cases (37.9%) and 200/380 (52.6%) of cases had the potential for an impact:

ImpactNumber of patients affectedStep where error occurred
Minor21 patients (5.5%)Result communication: 13 All other steps: 8
Moderate34 patients (8.9%)Result communication: 12 All other steps: 22
Major89 patients (23.4%)Result communication: 45 All other steps: 44
No impact noted236 patients (62.1%)