Why it matters

Millions of patients are successfully scanned every year in radiology units across the UK. However, over 1,000 incidents where the wrong patient or wrong site was scanned were reported to the Care Quality Commission in 2018/19. Of these incidents, over 90% were categorised as ‘human error’.

Previous improvement studies in this area haven’t considered the wider contextual factors involved in these incidents, and that irradiation of the incorrect patient is often due to system failure rather than solely human action. Improvement initiatives have often taken a narrow approach, changing only one element of the system in isolation.

Our approach

This study took a human factors and ergonomics approach to reducing the risk of patient identification errors in radiology. It looked at several influences involved, from person level to whole organisation level. The aims were to reduce the risk of wrongly identifying patients in radiology, to increase reporting of near misses, and to introduce a systems approach to incident reporting.

The study took place at a large NHS foundation trust with four hospital sites. The researchers worked closely with radiographers and managers, observing current working practices, reviewing incident data and carrying out risk analysis.

Interventions that impact the environment as well as people’s behaviour were introduced, including adapting the workspace to reduce distractions and interruptions; developing a standard operating procedure for patient identification; introducing wristband barcode scanners; and holding workshops for radiology staff. These were designed to encourage a broader consideration of work system factors and increase reporting of near misses.

What we found

The study demonstrated that the risk of scanning the wrong patient or the wrong site is influenced by each level of the system. Simple changes to the environment, for example, were shown to reduce the number of distractions, allowing radiographers to concentrate better. The development of a standard operating procedure with a user-centred design approach engaged staff and provided an accessible prompt to good practice.

Following implementation of the interventions, interruptions in the radiology control rooms decreased by 34 per cent. Anecdotally, there were reports of a calmer working environment. The interventions were associated with a decrease in patient identification incidents and an increase in near miss reporting. A total of 156 staff members attended the workshops (from a target of 180).

The study applied both traditional safety-control methods to risk management with newer concepts from resilience engineering. These two perspectives are sometimes seen as opposing; this project indicates that they can be succesfully used in combination.

The safe provision of imaging across different locations is a challenge for many radiology departments. This study demonstrated that taking a multi-level human factors and ergonomics approach can reduce the risk of patient identification incidents.