A national study of the causes, consequences and amelioration of adverse events in the use of MRI, CT, and conventional radiography in Norway.

ABSTRACT

BACKGROUND: Rapid technological developments, increased complexity, and increased demand have made patient safety a challenge in radiology. PURPOSE: To uncover the causes and consequences behind patient injury compensation claims in the use of MRI, CT, and conventional X-ray examinations, and to determine the system factors that need to be focused on in order to prevent these events. MATERIAL AND METHODS: This descriptive cross-sectional study uses data acquired from The Norwegian System of Patient Injury Compensation. A total of 240 cases from 2012-2016 were included. RESULTS: According to our study, the main factors contributing to patient injury compensation claims in radiology were false-negative findings (48.7%), misinterpretation (13.1%), and "satisfaction of search" (12%). Another source of error was routines (8.7%), mainly where the patient should have been (further) examined using another modality. Other causes were related to communication (7.6%), procedures (2.9%), technical factors (2.5%), organizational and management factors (1.5%), competence (0.7%), location of the lesion (0.7%), patient factors (0.7%), false-positive findings (0.4%), and work environment (0.4%). These events led to delayed diagnosis and/or treatment in the range of 0-3650 days. CONCLUSION: Errors of perception (false negative and "satisfaction of search") and cognitive errors (misinterpretation) were the main reasons behind patient injury compensation claims in radiology. We suggest that a combination of double-reading, specialization, increased collaboration between professionals, as well as a reduction of unnecessary examinations should be considered to reduce adverse events in radiology.