Improving patient safety through the use of a tracking system

Objectives To create a safe patient environment and to abide by the Joint Commission’s National Patient Safety Goal of minimizing the occurrence of wrong patient, wrong site, or wrong procedure events.

Methods Mayo Clinic Arizona Department of Radiology has utilized a Safety Event Reporting Form (SERF) to record all types of occurrences for several years. The submissions are reviewed and recorded for the individual work areas and the department as a whole to identify and correct any trends. Mayo Clinic practices in a “fair and just culture.” Events are encouraged to be reported and are non-punitive. The reports are used for process improvement.

Results In 2013, Nuclear Medicine had 36 inappropriate exams where the order that was placed was not the intended or appropriate exam. No incidences of wrong patient or wrong site were encountered. Only two of the exams were actually performed. The remainder were corrected, a majority of the time prior to the actual appointment date. When a questionable exam or indication is encountered, the technologist will review the electronic medical record (EMR) and discuss the patient with the Nuclear Medicine radiologist and ordering physician. This allows the order and appointment scheduling to be corrected and any changes in patient preparation and dose ordering to be made.

Conclusions Through the use of the SERF tracking system, patterns in inappropriate exam ordering can be identified. The ordering staff is educated regarding the inappropriate ordering in an effort to minimize future incidents. New exam orders are created when needed to better clarify what is being ordered. The technologist and physician staffs are acutely aware of the need to review the EMR for any questionable exams to confirm that the proper exam is performed. This attention to detail allows the exam order to be corrected prior to initiating the procedure. To appropriately maintain patient safety, events of all types should be reported and tracked. Any trends or significant events can be addressed to prevent future occurrences.