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ABSTRACT The purpose of this study was to estimate the prevalence of reported mis
wrong patient event in radiology. An institutional imaging report database
was searched for reports between January 1, 2009, and May 30, 2013.
Overall, 67 eligible report were identified among 1,717,713 examinations
performed during the study period. The number of near-miss mislabelled
patient events for imaging test and the delay in awereness of these events
were substantial, especially for radiography.
INTRODUCTION The purpose of this study was to estimate the prevalence of reported
nearmiss wrong-patient events in radiology at two large academic hospitals
and its relation to imaging modality, clinical setting, and time of
occurrence.
DISCUSSION The results of our study showed that the average monthly incidence of
near-miss wrongpatient events is 0.7 (SD, 0.9) for
mislabelingmisidentification events and 0.6 (SD, 0.7) for wrong dictation
events. Even after adjustment for the volumes of each modality performed,
portable chest radiography had the most mislabeling-misidentification
events. The time from occurrence to identification of wrong dictation
events was significantly less than that for mislabeling-misidentification
events (median time, 0 vs 22 hours; p = 0.02)