Classifying Safety Events Related to Diagnostic Imaging from a Safety Reporting System using a Human Factors Framework

PURPOSE: To measure diagnostic imaging safety events reported to an electronic safety reporting system (ESRS) and assess steps where they occurred within the diagnostic imaging workflow and contributing socio-technical factors. METHODS: We evaluated all ESRS safety reports related to diagnostic imaging during calendar 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and performing 680,000 diagnostic imaging studies annually. Each report was assigned a 0-4 harm score by the reporter; we classified scores of 2 (minor harm) to 4 (death) as “potential harm”. Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and socio-technical factors per the Systems Engineering Initiative for Patient Safety (SEIPS) framework. Kappa measured inter-reviewer agreement on 10% of reports. The percentage of reports that could cause “potential harm” was compared for each step and socio-technical factor using chi-square analysis. RESULTS: Of 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was Imaging Procedure (54% of reports), potential harm occurred more in Report Communication (Odds Ratio=2.36, p=0.05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to Task compared to Person factors (OR=5.03, p<0.0001). Kappa was 0.79. CONCLUSION: Safety events were related to diagnostic imaging in 7% of reports and potential harm occurred primarily during Imaging Procedure and Report Communication. Safety events were attributed to multifactorial socio-technical factors. Further work is necessary to decrease safety events related to diagnostic imaging.