Learning from incident reports in the Australian medical imaging setting: Handover and communication errors
journal contribution
posted on 2025-06-03, 04:59 authored by N Hannaford, C Mandel, C Crock, Kristal BuckleyKristal Buckley, F Magrabi, M Ong, S Allen, T SchultzObjective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence. Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n5298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging. Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion: The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information technologies, patient transfer and inadequate test result notification policies are relevant to all healthcare settings. © 2013 The Authors.
History
Journal
British Journal of RadiologyVolume
86Article number
20120336Location
Oxford, Eng.Open access
- No
ISSN
0007-1285eISSN
1748-880XLanguage
engPublication classification
C1.1 Refereed article in a scholarly journalIssue
1022Publisher
Oxford University PressUsage metrics
Keywords
AdolescentAdultAgedAged, 80 and overAustraliaChildChild, PreschoolCommunicationDelayed DiagnosisDiagnostic ErrorsDiagnostic ImagingFemaleHospitalizationHumansInfantMaleMedical ErrorsMiddle AgedPatient HandoffPatient SafetyReferral and ConsultationRisk AssessmentTransportation of PatientsYoung AdultBiomedical Imaging8.1 Organisation and delivery of services
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