Incidence and Classification of Incident Reporting in the Interventional Radiology Department of a Large Multicenter Tertiary Care Institution

There is a paucity of data surrounding errors and patient safety incidents in interventional radiology (IR).  Limited published data so far highlights its multifactorial nature given its unique position as both an imaging-based and procedural-based speciality. This study describes the incidence of safety incidents, identifies its etiologies and trends, and potentially strategizes quality improvement opportunities at a multicenter tertiary-care IR department with a goal of optimizing patient safety and minimizing errors in IR.

Materials and Methods:

Retrospective review of all safety incident reports within our Vascular and Interventional Radiology Department between January 1, 2012 and December 31, 2020 was conducted using the prospectively maintained institutional Safety Event Reporting Portal. Project approval was obtained from institutional Quality Improvement Committee.

Results:

During our study period, a total of 840 safety incident reports were reviewed and categorized based on etiology and level of harm. Communication issues are the most common source of safety reporting (21%; n=177) and were subcategorized into requisition errors (6.0%; n=50), lack of communication of isolation status (6%; n=50), and lack of communication of cancelled procedure requests (4.0%; n=33). Inadequate pre-procedural preparation accounted for 12.5% (n=105) of cases while transportation delays, insufficient documentation, and equipment issues accounted for 9.3% (n=78), 8.8% (n=74) and 8.3% (n=70) of all cases respectively. Resultant delays in care were observed in 30.5% (n=256) of cases. Near miss events accounted for 35.4% of reports (n=297), 43.1% (n=362) caused no harm but reached the patient, 12.3% (n=103) resulted in temporary or minor harm, and less than 0.5% (n=38) led to major harm or death.

Conclusion:

This study highlights the types of safety events that have occurred in a tertiary referral IR department over a nine-year period. This adds to the limited literature on safety within interventional radiology and aids in the understanding of the types of errors that can occur which can be targeted for quality improvement. Importantly, this study also evaluates non-procedural related safety event data that is critical for optimizing operational management.