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Medical Errors- Safety Practices and Reducing Errors in Radiology Back to Course Index





Dr. Arthur Bloomfield is quoted as saying, “There are some patients we

cannot help….There are none we cannot harm”


One of the most dangerous times in the hospital for a patient is when they are wheeled out of their room for any myriad of tests.  Of particular concern recently due to the analysis by the United States Pharmacopeia, a nonprofit group that sets standards for the drug industry, is the patient visits to the radiology department for a test or a procedure.  According to their report in 2006 medication errors that harm patients are seven times more frequent in the course of radiological services than in other hospital settings.


Across the departments, experts estimate that in any given year more people die from medical errors than from automobile accidents, breast cancer or AIDS.  The number of reported medical errors is continuing to rise throughout the nation and public safety has been spot lighted as a major concern by consumers, the media and regulators. Due to these trends the federal and state governments, regulatory agencies and health care organizations have made safety a key priority in providing quality healthcare in every area.  Patients have a right to expect healthcare free from accidental injury and risk and healthcare workers have an expectation of working with organizations that support safe and effective care. 


This course was developed to provide a foundation for a better understanding of what medical errors are, where they most frequently occur, how they effect radiology personnel and patients, how to address them using processes such as the root cause analysis and how to avoid them in any clinical setting, and specifically in radiology through error reduction and prevention techniques. Current industry changes including the Florida Hospital Association, Joint Commission patient safety standards and Presidential and Congressional activities will be identified.  Culture changes, analysis tools and improvement approaches reporting processes, risk management issues will be discussed.  Finally, individual practioners issues related to medical errors, such as medication errors and other aspects will be reviewed.  These topics will discuss ways to promote safety and improve outcomes for patients including special populations.  Patient and family participation will be highlighted as a key component of safety. 



Magnitude of the Problem


The serious problem of medical errors is not new, but historically the issue has not gotten the attention it deserves.  How did the focus of patient safety come to the attention of the nation?  The Institute of Medicine (IOM) was established in 1970.  It serves as an advisor to the government to identify issues of medical concern, research and education.  A body of research describing the problem of medical errors predominately in the hospital setting began to emerge in the early 1990’s.  In 1998, the final report of the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry identified medical errors as one of the four major challenges facing the nation concerning improving the quality of health care.  The first of the series of programs developed by the IOM, To Err Is Human:  Building A Safer Health System was released in 1999 with staggering results.  The research demonstrated that there were between 44,000 and 98,000 deaths resulting from adverse events.  Even using the lower estimate this would make medical errors the eighth leading cause of death in the United States.  Approximately 7,000 people per year die from medication errors alone.  Adverse events occur in 2.9 to 3.7 percent of all hospitalizations causing an excess of 17 billion in lost income, disability and additional health care costs. 


In a recent national poll, 42% of the respondents reported being affected by a medical error (either personally or through a friend or relative) worse still is that 32% indicated that the error had a permanent negative effect on the patient’s health. A national survey found that Americans are “very concerned” about errors: 61% feared being given the wrong medicine; 58% feared being given two or more drugs with a bad interaction; and 56% feared complications from a medical procedure.


Specific to radiology, the above noted  study was conducted by the USP which showed that more than 2.5 billion imaging procedures were conducted during the 5 year (2000-2004) period researched. Even taken at face value, the 2,030 errors cited in the report represent an error rate of .00008%. This rate is more than 3,700 times better than the lowest hospital wide medication error rate (.3%) cited by a recent Institute of Medicine report on this issue.

With this being said, Errors in radiology such as administering an improper dose of radiation or an unauthorized drug can result in considerable harm to patients. Medications such as blood thinners, dyes and sedatives routinely used in many interventional radiologic procedures can raise the stakes even higher.


Why Medical Errors Occur


A safe health care environment is one that promotes the health, safety and well being of patients, families, and employees, while reducing the possibility of error or incident.


Most people believe that medical errors are the result of the failures of individual providers.  When asked in a survey sixty-nine percent of respondents thought the problem could be solved through “better training of health professionals.”  In actuality, the IOM emphasized that most of the medical errors are systems related and not attributable to individual negligence or misconduct.  The professionalism model—“Blame and Shame”—has outlived its purpose. The best approach to reducing medical errors is to focus on improving the systems for caring for and treating clients and not to blame individuals. 


Health care professionals are humans and, like everyone else, they do make mistakes.  Safety must be considered at a systems level, as well as an individual one.   A variety of factors, such as workload, stress, financial forces and organizational culture play a role in creating potentially unsafe conditions.  Although research has shown that system improvements are key to reducing the error rates and improving the quality of health care it is also important to explore why professionals are prone to mistakes.  Research in the health care industry, as well as in other industries such as long distance trucking, aviation and nuclear power, have offered insight into why people make mistakes and how we can use this learning to improve systems and make patient care safer.  Much research supports that people make mistakes due to fatigue.  Mistakes are more likely as people get tired.  Inattention and distraction, when multiple events are occurring at the same time, can divert attention away from the primary task at hand.  Also, seeing what we expect to see because we are used to seeing it that way, even if it is incorrect often leads to mistakes that we don’t even recognize.  Encountering a new situation in which a clinician has not been trained and does not know how to handle can lead to using trial and error solutions that often resulting in error. 


Communication problems and information transfer problems, (this would include lack of communication, misinterpretation and using words that have more than one meaning) can contribute to errors.  Legibility issues, such as handwritten notes and orders that are poorly written, can lead to guessing, which can in turn lead to an error.  In the hospital setting, the labeling of medications or mislabeling equipment instructions may be misleading.  Frequently, mistakes are made when the equipment, supplies or the environment are not conducive to the safest practices. 


Systems and/or processes may fail due to variable or flawed input, inconsistency, complexity of the task, too many steps, too complicated of steps, human intervention, tight time constraints, and hierarchical culture.


We will explore these further later in the course.


Patients at Risk

Although, it is easy to think of the areas in the medical/surgical arena that medical errors could occur.  In actuality, many disciplines are vulnerable to errors.  They can occur in nursing, dietary, physical therapy, occupational therapy, radiology, nuclear medicine, laboratories, surgery, social services and many others.


There are a variety of reasons that harmful errors are likely to occur in the radiology suite. These include the fact that patients often receive potentially dangerous drugs such as dyes, sedatives and blood thinners, and their care is being handed off from one department to another, creating the opportunity for communication failures.


Those patients at the highest risk for falling prey to a medical error are those members of traditionally vulnerable populations who are less able to advocate for themselves. These populations include: children, the elderly, anesthetized patients, pregnant women, those with chronic mental illness, disabilities, minorities, and the uninsured.


Technological Resources

 A process that involves human intervention is more prone to error than one that is automated and under computer control.  Consequently, in an effort to streamline systems and remove “human error” some medical centers have increased the use of computer programs and other automated control systems. Even simple computer systems that use electronic prescriptions in place of handwritten ones have, in some cases, already paid off with substantial error reductions. Automated functions often proceed smoothly and without interruption, computer alerts, and calculators are examples of technology that maintain process stability without needing people to do the work.  Electronic patient records can also help to minimize errors by making patient information readily available for all health care professionals.



Systems can also fail. Raymond Woosley, MD, a professor and chairman of pharmacology at Georgetown University Medical Center, cites the example-“It’s true that if you have a prescription drug with an electronic bar code on it—the right code—it can help prevent errors. But if the wrong code is on there, you may have even more errors. There will always be mistakes, though they will be different mistakes as the systems change. You’ve got to be ready to handle them”


Despite technological advances, preventing mistakes will always depend on the vigilance of the helping professional.  If not for this vigilance human carelessness can render useless the very systems designed to avoid mistakes. 



Reporting Medical Errors  

Proper incident reporting identifies problem areas and it helps to provide the necessary information to establish safe practices, systems to ensure proper treatment and accurate files and to improve staff development.  There are several barriers to reporting mishaps including lack of time, fear of punishment, losing referrals, of being wrong, unclear reporting structures, or forgetfulness.  An established line of communication through your supervisor will assist in the performance improvement processes.  The goal of any reporting system should be to analyze the information gathered and to identify ways to prevent future errors from occurring. 


Although more than 20 states have mandatory reporting requirements, state officials say that underreporting persists.  Most experts agree that mandating medical error reporting in itself will not ease the hesitancy of doctors who are concerned with litigation or nurses concerned with losing their jobs.


Let’s face it, we all make mistakes.  Mistakes happen in hospitals, they happen in outpatient settings, and they happen in nursing homes.  We as professionals need to feel safe enough and respect our profession enough to acknowledge that they happen.  The challenge is to avoid them, and when mistakes do occur, to minimize or prevent them from causing harm to our patients.  While understanding the legal ramifications of such, we must admit that we made a mistake so that others and we can learn from it. 


Accidents are not isolated events; they are the result of a weakness in a system.  Other industries realize that faults in the system lead to errors and they have designed changes in the system itself to minimize errors.  For example, the auto industry has spent a great deal of money and time trying to improve cars to reduce driver error.  Examples include bells that sound when a door is ajar; child locks so children can’t open the doors the minute they can reach the handles (trust me, the handles become a favorite play item by about the age of 17 months!)  On my vehicle the door won’t lock from the outside without a key, so I’ve never locked myself out of the car.  Believe me, if I could have, I would have.  Health care professionals are accountable for their knowledge, for their competence and their work.  Blame is used to find an excuse for failure not to predict and prevent future incidents.  A blameless environment promotes comfort to report failures for study.  What happened versus whose fault is it.  “What” uncovers facts, “who” always places blame. 


Types and Causes of Errors

 A medical error is an act, or failure to act, that is not an appropriate component of a patient’s treatment regimen. Medical errors can cause little or no harm, moderate harm, or very serious harm, including death.  The term “adverse event” is used to describe an injury caused by medical mismanagement rather than an underlying disease/condition of a patient.  The term error planning is used to describe the use of a wrong plan to achieve the desired aim and error execution is used to describe the failure of a planned action to be completed as intended.  Not all, but a sizable number of adverse events are a result of medical errors.  Careful analysis followed by implementation of an effective process change can help prevent these errors from happening in the future. 


A “sentinel event” is defined as an event during care that results in major permanent injury or unanticipated death.


Medical errors may stem from wrong site surgery, equipment failure, improper use of medical devices, delay in initiating treatment, patient falls, drug interactions, look-alike labels, post-op complications/infections, diagnostic errors, misinterpretation of test results, illegible handwriting, ambiguous abbreviations or symbols and communication issues.


Organizations that do not have a procedure to check and double check the patient’s identity, the correct surgical site, the correct procedure, the correct position and the availability of proper equipment are at high risk for the occurrence of surgical medical errors. Because of the prevalence of these types of errors, The Joint Commission (JCAHO) has mandated that a universal protocol for the prevention of wrong-site, wrong-procedure and wrong-person errors be implemented by July 2004.

Sentinel Events 

In an effort to reduce the occurrence of sentinel events, The Joint Commission began tracking and has identified a number of recurrent problems, along with their root causes, and made recommendations for corrective action. The top 4 sentinel events since the inception of JCAHO data collection are:

  1. Inpatient Suicide
  2. Intra- and Post-Operative Complications
  3. Wrong Site Surgery
  4. Medication Errors                                                                                                                                                


Although the first three are not closely related to the radiology department the fourth bares further study as well as many other areas of specific concern.


Medication Errors

The IOM study estimates that as many as 7,000 patients die each year as a result of medication errors with an estimated additional hospital cost of 4,700 dollars for each preventable medication error.  Medication errors can be broadly categorized into 4 major categories.  The first, ordering and prescribing accounts for 39%.  The second, dispensing is approximately 12%.  The third, administration is 38% and transcribing is 11%.  So, almost 80% can be described as order, prescribing or administration. 


The American Hospital Association lists these as some common types of medication errors:

  • Incomplete patient information
  • Unavailable drug information
  • Miscommunication of drug orders.  This can be due to sound alike medications, poor handwriting, misuse of zeroes and decimal points, confusion of metric and other dosing units and inappropriate abbreviations.
  • Lack of appropriate labeling as a drug is prepared and repackaged into smaller unity
  • Environmental factors


Lack of patient information due to inadequate intake procedures, language barriers and miscommunication during the various stages of the medication administration process can lead to errors.  It is crucial to check for appropriateness and screen for allergies. The following can minimize these problems:

  • Ensure patient information is current and available consistently
  • Include critical patient data: known allergies, DOB, Hgt, & Wt.
  • Know the diagnosis and treatment plan


The JCAHO has identified 5 high alert medications along with their risk factors, these include:



·        Lack of dosage check systems

·        Storing insulin and heparin vials near each other, leading to mix-up’s

·        Using “U” as an abbreviation for “units”, “U” can be confused with “0” causing a 10-fold overdose

·        Infusion pumps being programmed with incorrect rates


Opiates and Narcotics

  • Storing parenteral narcotics in nursing areas as part of the floor stock
  • Confusing hydromorphone and morphine
  • Errors concerning the concentration and rate of patient-controlled analgesia (PCA)


Injectable Potassium Chloride or Phosphate Concentrate

  • Storing concentrated solutions of these drugs outside of the pharmacy
  • Mixing potassium chloride or phosphate without a careful check system
  • Complying with requests for unusual concentrations


Intravenous Anticoagulants (Heparin)

  • Concentration and total volume not labeled clearly
  • Storing multi-dose containers
  • Confusion can exist between heparin and insulin due to similar measurement units and storage in close proximity


Sodium Chloride Solutions above 0.9%

  • Storage of NaCL solutions (above 0.9%) on nursing units
  • Having large and varied numbers of concentrations and formulations available
  • Lack of double-check system

Dosing Errors

Frequent issues:

  • Giving an incorrectly ordered dose
  • Miscalculating the dose
  • Wrong dose being sent by pharmacy
  • Taking the wrong dose from patient’s medication storage
  • Borrowing a dose from another patient’s supply


Ways to Minimize Medication errors:

  • Double check references if unfamiliar drugs are ordered
  • Use meds in ready-to-administer form
  • Use manufacturer prepared IV solutions or pharmacy based admixture program
  • Prepare of obtain pre-calculated conversion cards
  • If you must calculate a dose, have someone check your calculations
  • Do not crush or split doses unless directed, by pharmacy, to do so
  • Read the label THREE times


MRI Safety Issues


The hazards associated with MRI magnets attracting metal objects are fairly well documented and most individuals who work with MRI equipment have been trained regarding how to protect themselves and others.  It is also fairly well known that as the higher-powered magnets (3.0 Tesla and higher) are introduced into the workplace there will be a corresponding increase in the hazards.  Although we depend on our senses (sight, smell, feel, etc.) to alert us to potential hazards; unfortunately, the MRI equipment is rather benign and does not smell or give off any visible signs that would indicate an active state (no one can see or smell a magnetic field).  As a result, when an unsuspecting worker or patient with a metal object (such as an ferromagnetic oxygen cylinder) is exposed to this environment a catastrophic outcome may occur as the forces of the magnetic field act upon the object and attract it toward the core of the magnetic.  The object can accelerate rapidly and become a projectile that may harm an individual or damage equipment.     


In the clinical setting, the principal surrounding “standard of care” are implemented to serve and protect patients in the MRI area.  In general, the standard of care is based on accessibility, availability, and best practices (those that are established in the industry) for delivery of service to the patient.  This approach is dependent upon the expertise, training and professionalism of the MRI staff to assure safety of patient and support personnel; accordingly, we are all human and some are more dedicated to providing safe health care than others; consequently, there has been numerous incidents of unsafe practices in the MRI industry.  Most are looked at as operational issues or explained away as operator error with a recommendation to increase training or supervision.  However, MRI safety is still a concern and most believe that it must be addressed at the facility (site) level, as well as at the operational level.  The best approach to increasing operational safety is through implementation of comprehensive MRI safe-practice standards while continuing to implement effective personnel training and certification.  This approach should increase overall awareness of the hazards inherent in the MRI industry and how to prevent/avoid injuries to personnel and damage to equipment.  


Much focus regarding the safety patients in the radiology department has been on site access restriction.  More attention must be applied to design and layout of the department or facility.  It is now fairly standard to employ a layout that consists of four zones with varying levels safety practices invoked for each. 


Additionally, related to the MRI patient, several precautionary measures need to take place such as the removal of all readily removable metallic personal belongings and devices on or in them, and the screening of patients for whom an MR examination is deemed clinically indicated or necessary but who are unconscious or unresponsive or who cannot provide their own reliable histories regarding prior possible exposure to surgery, trauma, or metallic foreign objects and for who such histories cannot be reliably obtained from others it is recommended that such patients be physically examined by MR personnel. 


Children are the largest group of patients requiring sedation for MRI, because they lack the ability to remain motionless during scans.  Adherence to standards of care mandate sedation providers following the guidelines developed by the American Academy of Pediatrics, the American Society of Anesthesiologists, and the Joint Commission on Accreditation of Healthcare Organizations.  Also, sedation providers must comply with the protocols established by the individual state and the practicing institution.  The guidelines require the following provisions:


o       Medical history and examination for each patient

o       Adherence to fasting guidelines appropriate for age

o       Uniform training and credentialing for sedation providers

o       Intra-procedural and post-procedural monitors with adapters appropriately sized for children (compatible with the magnetic field).

o       Method of patient observation

o       Resuscitation equipment, including oxygen delivery and suction.

For the neonatal and the young pediatric population, special attention is needed in monitoring body temperature in addition to other vital signs.  Also, ensure specialty items such as neonatal isolation transport units are MR compatible. It is also common for pediatric population to request/require an accompanying parent or guardian during the MRI procedure; consequently, those accompanying or remaining with the patient should be screened using the same criteria as anyone else entering Zone IV.


Patients in Whom There Are or May Be Cardiac Pacemakers or Implantable Cardioverter Defibrillators:  It is recommended that the presence of implanted cardiac pacemakers or implanted cardioverter defibrillators (ICDs) be considered contraindicated for routine MRI.  Should an exception be considered, it should be done on a case-by-case and site-by-site basis and only if the site is manned with individuals with the appropriate radiology and cardiology knowledge and expertise on hand.


Falls Prevention

Patients are at risk for serious injury and organizations must deal with the financial liability that results from such accidents.  Those who are at most risk for fall are the elderly or those under the influence of alcohol, other drugs or heavy medications.  Falls may be caused by environmental factors, such as clutter in the room, wet floors, rugs; psychological factors; muscle problems or broken bones; incomplete histories or lack of identification of fall risks. 


Cultural Changes

Research clearly shows that the majority of medical errors can be prevented.  A landmark study on medical errors indicated 70 percent of adverse events, found in a review of 1,133 medical records, were preventable; 6 percent were potentially preventable; and 24 percent were not preventable.  It is a common misconception that client safety can be improved by simply reminding health care personnel to be more careful.  To correct medical errors the focus should be on reviewing the processes and factors that surrounded the event instead of focusing on blaming an individual for an incident.  A change in focus can occur only when health care professionals carefully evaluate their processes and previous errors and then systematically making positive changes.  Improving patient safety is about changing the culture in health care.  There are several models that are used to illustrate these points.  The Swiss cheese model described by LifePoint Hospice, illustrates that an accident is not the result of one single failure.  When an accident occurs it is a result of a series of failures aligning thereby allowing the mistake to reach the patient.  Visualize several pieces of Swiss cheese. The slices would represent the defenses that are built into organizations to prevent failure and error.  But the holes on each slice of cheese, randomly positioned, represent the opportunity for failure.  Each time we would layer those slices, those holes might be in different locations and at some given point in time, all of the holes in each slice might all line up so that something could occur and fall down that hole and ultimately reach the patient.  So although there are many types of defenses, organizations have to protect the patient from errors, to help minimize the vulnerability, organizations need to systematically examine how failures move past the defenses that are in place.


“Hindsight is 20/20”.  Hindsight bias is the phenomenon where it seems obvious how an error happened, but after the fact.  However, before the error occurred it was not obvious that the process or system was error prone.  Hindsight bias is detrimental to accident analysis and understanding because it narrows the focus of the cause of any failure without considering the whole picture including all of the environmental and emotional issues, which may surround the event.   This approach will limit a complete and thorough investigation and focus on individual action as the cause of the problem.  We often jump to conclusions without having all of the necessary information.


Root Cause Analysis

Most researchers have concluded perfecting the technical work of individuals will not prevent the majority of medical errors, instead implementing prevention techniques as a means of crosschecking and monitoring progress is necessary to improve outcomes.  To implement these techniques it is necessary to utilize prevention analysis.  In the scientific process of error reduction and prevention there are two models that study the prevention of errors and patient safety.  The first model is applied before an error occurs and is designed to prevent errors by examining processes to determine failure points and risks.  While several approaches can be used such as checklist analysis, “what if” analysis and barrier analysis, the most common model used and the one identified by the Joint Commission is the Failure Mode and Effect Analysis (FMEA).  FMEA is a proactive approach.  The model is applied after the event occurs and is designed to identify the multiple factors that contributed to the event so the corrective action can be taken to prevent future adverse events.  The approach uses a process called Root Cause Analysis, RCA.  Although it is termed “root” cause, rarely is a single cause found to contribute to the error.  Usually multiple causes are found and each cause will need to be assessed and prioritized for correct action. 


FMEA assumes that no matter how knowledgeable or careful people are, errors will occur in some situations and may even be likely to occur.  FMEA steps include first defining high risk processes, identifying what could go wrong, the significance of the error and what needs to be done to prevent failures.


Root cause analysis, or RCA, is a process for identifying the causes that affect performance.  This includes the occurrence or possible occurrence of a sentinel event.  Such events are called sentinel because they signal the need for immediate investigation and response.  This analysis determines what happens during these events, why it happens and helps to determine what the underlying causes were.  Then it defines a corrective action plan or plans, implements the plan and measures the effectiveness of that plan.  RCA steps include the following:  1) defining the problem and gathering the facts.  2) assembling an interdisciplinary team. 3) determining the sequence of events, the order in which they happened.  4) identifying contributing factors. 5) selecting root causes of the event. 6) determining the appropriate actions and the necessary follow-up plan.

Since the vast majority of errors are system (not people) related, they are therefore preventable. Consequently, systematic root cause analysis can help identify the underlying problems (error prone situations) so that corrective action (systematic error reduction strategies) can be put into place.


To extract the root cause of a sentinel event, it’s helpful to think of the root cause as an accumulated series of smaller events. Tracking back through these events leads to a proximate cause, which is the main reason for the incident. Commonly, the causes are systemic problems that could lead to other incidents or injuries. Risk points indicate where organizations could have avoided the event if extra care had been taken.


The staff with the direct contact with the clients is the last line of defense between effective care and a potential error.  If we wish to accomplish our goal of protecting the patient from medical errors then we must be proactive at examining risk prone areas in which we work.  Many times we “get lucky” and have what can be termed a “near miss”.  A near miss error can be described as an error that got caught before it reached the patient.   Identifying and analyzing errors that are considered near miss errors can give us the opportunity to prevent future harm by determining where the weak parts are in the care delivery system and then strengthening those areas. 


10 Concepts for Reducing Errors

The Institute for Healthcare Improvement presented 10 concepts for reducing errors to the American Hospital Association.


     1.  Standardize: limit unneeded variety in drugs, equipment, supplies,

         rules, and/or procedures.

     2.  Simplify: reduce the number of steps, nonessential elements, and/or


     3.  Stratify: avoid “one size fits all”

4.  Improve communication: use standard vocabularies, repetition, and

     “hear backs.”

5.  Support “team” communication: use group processes that promote 

     (not discourage) information exchange from bottom to top and top to


6.  Use defaults properly: design processes so that doing the “right” thing

     is the easiest thing to do and requires the lowest energy expenditure.

7.  Automate cautiously: avoid over-automating; but do so in a way that is

     operator-friendly and has effective overrides if needed.

8.  Use affordances and natural mapping: design

     equipment/environment so that physical shapes and flows-and visual

     controls- guide proper use.

9.  Respect human limits: recognize issues of stress, workload, time

     pressure, circadian rhythm, limits to memory and vigilance, etc. Use

     checklists as reminders to ensure complete accurate actions. 

10. Encourage reporting of errors and error prone situations: use

     anonymity, reward reports; build a culture that lauds increase of

     knowledge in mitigating errors.


Specifically, additional education for radiologic technologists in the following topics can prevent and reduce errors:


  • The proper use, indications and routes of administration for contrast media and other medications used in radiology.
  • Pharmacology, including drug interactions and contraindications.
  • Charting and documentation techniques.
  • Use of electronic medical records and information access and retrieval systems.
  • Communication skills as members of an interdisciplinary health care team.



Although most medical errors are not the result of sheer irresponsibility, negligence is a factor.  JCAHO defines negligence as “a failure to use such care as a reasonably prudent and careful person would use under similar circumstances.”

There are 6 major categories of negligence that result in malpractice lawsuits:

1.     Failure to follow standards of care

2.     Failure to use equipment in a proper, responsible manner

3.     Failure to communicate, including inadequate transfer of information

4.     Failure to document properly

5.     Failure to accurately assess and monitor

6.     Failure to act as an advocate for the patient


Patient Education

Communication from the initial consent to treat to disclosure of an unanticipated outcome is paramount to effective, therapeutic safe care.  Communication is the key.  All providers involved in the course of treatment should maintain open communication with the patient and as appropriate the client’s family.


Clients develop through a variety of ways, seeing, hearing, touching and doing.  Remember to incorporate as many techniques as possible to ensure the maximum amount is learned and retained.  Frequently, providing brochures and other written materials can help to emphasis how the client and their family can better understand and help their treatment along.  Encourage patients to ask questions about their treatment plan and goals to be sure they understand. 


Patients and family members/caregivers need to understand the importance of being informed and vigilant when in a medical setting. The following recommendations should help patients and their families receive safer health care:

·        Ask questions! Bring someone with you, if you need to, to help ask questions. If you don’t understand the answer, ask for clarification

·        Maintain an accurate and complete list of all the medications you are taking, including OTC’s, vitamin and herbal supplements, and weight-loss products.

·        If given a prescription, inquire as to its purpose, side effects, foods or other things to avoid while taking it, and warnings. After it’s filled read the label. Is it what your doctor ordered? Do you know how to take it? If it doesn’t look like what you expected, ask the pharmacist before you take it.

·        Obtain the results of all tests and procedures, and ask for explanations in terms that are understandable

·        Discuss with healthcare providers what hospital is best suited to meet specific patient needs

·        If surgery is needed, clarify exactly what will happen, as well as the anticipated outcomes and risks.



With the shifting from blame and punishment to analysis of the root causes of medical errors together we are changing the culture of healthcare.  Every person on the healthcare team has a role in creating a safer environment for patients and workers.


If the number of errors in radiology “is not zero, we can get better,” says Atul Gupta, MD, director of interventional radiology at Paoli (Pa.) Hospital. “So having the spotlight on us is not a bad thing.”