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Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error

BACKGROUND: Strategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisc...

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Autores principales: Muench, Gloria, Witham, Denis, Rubarth, Kerstin, Zimmermann, Elke, Marz, Susanne, Praeger, Damaris, Wegener, Viktor, Nee, Jens, Dewey, Marc, Pohlan, Julian
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Springer Vienna 2022
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9636350/
https://www.ncbi.nlm.nih.gov/pubmed/36333572
http://dx.doi.org/10.1186/s13244-022-01313-5
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author Muench, Gloria
Witham, Denis
Rubarth, Kerstin
Zimmermann, Elke
Marz, Susanne
Praeger, Damaris
Wegener, Viktor
Nee, Jens
Dewey, Marc
Pohlan, Julian
author_facet Muench, Gloria
Witham, Denis
Rubarth, Kerstin
Zimmermann, Elke
Marz, Susanne
Praeger, Damaris
Wegener, Viktor
Nee, Jens
Dewey, Marc
Pohlan, Julian
author_sort Muench, Gloria
collection PubMed
description BACKGROUND: Strategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisciplinary conferences (MDCs), radiologists and ICU physicians re-evaluate recent examinations. Structured bilateral feedback is provided to identify errors early. This study aims at investigating its impact on the occurrence of QM events (imaging-related errors). Standardised protocols of all MDCs from 1st of June 2018 through 31st of December 2019 were analysed with regard to categories of QM events (i.e. indication, procedure, report) and resulting consequences. RESULTS: We analysed 241 MDCs with a total of 973 examinations. 14.0% (n = 136/973) of examinations were affected by QM events. The majority of events were report-related (76.3%, n = 106/139, e.g. misinterpreted finding), followed by procedure-related (18.0%, n = 25/139, e.g. technical issue) and indication-related events (5.8%, n = 8/139, e.g. faulty indication). The median time until identification of a QM event (time to MDC) was 2 days (interquartile range = 2). Comparing the first to the second half of the intervention period, the incidence of QM events decreased significantly from 22.9% (n = 109/476) to 6.0% (n = 30/497) (p < 0.0001). Significance of this effect was confirmed by linear regression (p < 0.0001). CONCLUSIONS: Establishing structured discussion and feedback between radiologists and intensive care physicians in the form of MDCs is associated with a statistically significant reduction in QM events. These results indicate that MDCs may be one suitable approach to timely identify imaging-related error. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13244-022-01313-5.
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spelling pubmed-96363502022-11-06 Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error Muench, Gloria Witham, Denis Rubarth, Kerstin Zimmermann, Elke Marz, Susanne Praeger, Damaris Wegener, Viktor Nee, Jens Dewey, Marc Pohlan, Julian Insights Imaging Original Article BACKGROUND: Strategies to identify imaging-related error and minimise its consequences are important in the management of critically ill patients. A new quality management (QM) initiative for radiological examinations has been implemented in an intensive care unit (ICU) setting. In regular multidisciplinary conferences (MDCs), radiologists and ICU physicians re-evaluate recent examinations. Structured bilateral feedback is provided to identify errors early. This study aims at investigating its impact on the occurrence of QM events (imaging-related errors). Standardised protocols of all MDCs from 1st of June 2018 through 31st of December 2019 were analysed with regard to categories of QM events (i.e. indication, procedure, report) and resulting consequences. RESULTS: We analysed 241 MDCs with a total of 973 examinations. 14.0% (n = 136/973) of examinations were affected by QM events. The majority of events were report-related (76.3%, n = 106/139, e.g. misinterpreted finding), followed by procedure-related (18.0%, n = 25/139, e.g. technical issue) and indication-related events (5.8%, n = 8/139, e.g. faulty indication). The median time until identification of a QM event (time to MDC) was 2 days (interquartile range = 2). Comparing the first to the second half of the intervention period, the incidence of QM events decreased significantly from 22.9% (n = 109/476) to 6.0% (n = 30/497) (p < 0.0001). Significance of this effect was confirmed by linear regression (p < 0.0001). CONCLUSIONS: Establishing structured discussion and feedback between radiologists and intensive care physicians in the form of MDCs is associated with a statistically significant reduction in QM events. These results indicate that MDCs may be one suitable approach to timely identify imaging-related error. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1186/s13244-022-01313-5. Springer Vienna 2022-11-04 /pmc/articles/PMC9636350/ /pubmed/36333572 http://dx.doi.org/10.1186/s13244-022-01313-5 Text en © The Author(s) 2022 https://creativecommons.org/licenses/by/4.0/Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ (https://creativecommons.org/licenses/by/4.0/) .
spellingShingle Original Article
Muench, Gloria
Witham, Denis
Rubarth, Kerstin
Zimmermann, Elke
Marz, Susanne
Praeger, Damaris
Wegener, Viktor
Nee, Jens
Dewey, Marc
Pohlan, Julian
Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
title Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
title_full Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
title_fullStr Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
title_full_unstemmed Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
title_short Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
title_sort imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error
topic Original Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9636350/
https://www.ncbi.nlm.nih.gov/pubmed/36333572
http://dx.doi.org/10.1186/s13244-022-01313-5
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