Never Events in Radiology and Strategies to Reduce Preventable Serious Adverse Events.

The term never event in medicine was originally coined by Kenneth W. Kizer, MD, MPH, former chief executive officer of the National Quality Forum, to describe particularly shocking medical errors that should never occur, such as wrong-site surgery or death associated with introduction of a metallic object into the MRI area. With time, the National Quality Forum's list of never events, or "serious reportable events," has been expanded to include adverse events that are unambiguous, serious, and usually preventable. In this article, the never event framework has been used to describe (a) the errors that may occur in an imaging department that are serious and usually preventable with a review of the causative factors and (b) strategies to eliminate and reduce the adverse effects of these avoidable errors. These errors are often rooted in communication breakdowns and can only be eliminated with a true shift to a culture of open reporting and patient safety. ©RSNA, 2018.

Developing Interventional Radiology Anticoagulation Guidelines: Process and Benefits †.

We created, posted, and updated radiology department anticoagulation guidelines and identified various steps in the process, including triggering events, consensus building, legal analysis, education, and distribution of the guidelines to nurses and clinicians. Supporting data collected retrospectively, before and after implementation, included nursing satisfaction survey results and the number of procedure cancellations. After the guidelines were developed and posted, significantly fewer procedures were cancelled, nursing satisfaction was higher, and radiologists performed procedures with less variability. Anecdotally, radiologists had fewer queries about anticoagulation. The development and dissemination of radiologic procedure anticoagulation guidelines should be considered as a departmental quality improvement project.

Diuretic Renal Scintigraphy in Patients with Sulfonamide Allergies: Possible Alternative Use of Ethacrynic Acid.

UNLABELLED: Furosemide may trigger life-threatening sulfonamide cross-hypersensitivity reactions, posing a dilemma in patients who need diuretic renal scintigraphy. METHODS: We present our experience using ethacrynic acid as a nonsulfonamide alternative diuretic in 5 patients, with a discussion of the diuretic molecular structure, potential side effects, protocol development, and imaging results. RESULTS: Diuretic renal scintigraphy using ethacrynic acid provided useful information about the obstruction status in all patients, with no adverse clinical impact. CONCLUSION: Ethacrynic acid is a potential alternative to furosemide for patients with severe sulfonamide reactions.

Designing a safer radiology department.

OBJECTIVE: Patients presume safety in radiologic services, but the potential to do harm exists in every area of imaging. Radiology department personnel need to understand basic regulatory requirements for safety and how to promote and improve safety in the future. CONCLUSION: This article reviews key safety metrics that we think are relevant to radiology and discusses how to define the measures and how we are attempting to translate the metrics into a culture of safety.