Quick two-person verification system reduces wrong-patient, wrong-study events

Wrong-patient and wrong-study events in radiology can be reduced by implementing a two-person verification system, according to a recent study published in the American Journal of Roentgenology.

Eva Ilse Rubio, MD, and Laurie Hogan from the Children’s National Health System department of radiology analyzed the impact of introducing a two-person patient and study verification system to a radiology department.

The verification system itself, eventually named “Rad Check,” was designed to be easy to learn and simple to use. Two individuals—technologists, nurses, physicians, transporters, desk clerks, or any health care professional—read the patients name and medical record number to confirm the study and then verbally confirm the study scheduled to be performed. It takes an average of 12.5 seconds to complete the Rad Check system.

The authors examined data from January 2009 to December 2014, gaining perspective from before and after Rad Check was introduced in July 2012.

Overall, there were 45 wrong-patient or wrong-study events from January 2009 to December 2014. Sixty-four percent of the incidents were wrong-study events, and 36 percent were wrong-patient events.

A total of 36 events were recorded in the 42 months before Rad Check implementation, which is approximately one error every 35 days. In the 30 months after implementation, nine events were recorded, or approximately one every 101 days.

There was not a single wrong-patient or wrong-study event in all of 2014.

“The Rad Check process is simple and flexible and has the potential to significantly reduce errors if implemented in a clear and stepwise fashion; we were able to achieve more than 410 consecutive error-free days and believe that it is possible to nearly eliminate these types of errors, substantially improving patient safety in our department,” the authors wrote. “We encourage the radiology community to consider wrong-patient or wrong-study errors as the next never event.”

The authors also explained that implementing and tracking verification systems such as Rad Check can lead to various issues. For example, if a department tracked wrong-patient and wrong-study events publicly, it would lead to the technologists feeling “unanticipated significant distress” if they were technically responsible for a mistake.

“The fear of public embarrassment will suppress error reporting,” the authors wrote. “Protecting the identity of staff members associated with errors is essential. Promoting the importance of error documentation to support the department's goal of finding a solution to wrong-patient or wrong-study errors and deemphasizing the individual's error will facilitate a culture of safety. The focus should remain on developing the optimal system for error reduction.”

The authors also warned against creating a system that punishes technologists for wrong-patient or wrong-study events.

“The consequences of committing an error should be carefully considered ahead of time; disciplinary actions are also likely to drive error reporting underground,” the authors wrote. “Project success will be false, and the process can breed resentment.”