Article Figures & Data
Tables
Error type Category Subcategory Definition TOP noncompliance Patient interview TOP Questions noncompliance Failure to ask “correct patient, correct site, correct procedure” questions Request form Errors due to incorrect patient details on request form (e.g., wrong patient sticker) Pregnancy/breastfeeding Errors due to failure to check for pregnancy and breastfeeding Procedural TOP Handover Procedure performed incorrectly because first person fails to properly hand over patient to second person (e.g., provides inadequate information) or second person fails to make appropriate checks Staff Procedure performed incorrectly because of human error (e.g., radiographer forgets to connect pressure injector to patient’s cannula) Internal systems Procedure performed incorrectly because of errors in procedures or systems within the department Procedure matching Errors due to failure to match patient presentation to procedure on request form Dose Errors due to administration of incorrect dose Radiopharmaceutical Errors due to administration of incorrect radiopharmaceutical Intravenous access Errors due to lack of proper intravenous access Request form Procedure performed incorrectly because request form was ambiguous Quality control Procedure performed incorrectly because staff failed to complete quality control test Booking errors Internal and external systems Booking errors before patient reaches MRS personnel, due to systems outside department (e.g., electronic x-ray requests) or within department (e.g., reception) Request form Booking errors due to use of duplicate or nonoriginal request form Other errors Students/new graduates Errors by students or new graduates due to inadequate supervision by MRS personnel Training Errors due to inadequate training on software, equipment, or procedures Exposure to radiation Errors causing the staff or the public to unintentionally be exposed to radiation Radiopharmaceutical spillage Errors causing a radiopharmaceutical to unintentionally be spilled MRS = medical radiation science.
Error type Incidents (n) TOP noncompliance 179 (85.6%) Patient interview TOP 26 (12.4%) Noncompliance 19 (9.1%) Errors in request form 5 (2.4%) Failure to check for pregnancy/breastfeeding 2 (1.0%) Procedural TOP 153 (73.2%) Handover error 4 (1.9%) Staff error 14 (6.7%) Errors in internal systems 3 (1.4%) Lack of procedure matching 15 (7.2%) Incorrect dose 15 (7.2%) Incorrect radiopharmaceutical 76 (36.4%) Lack of intravenous access 19 (9.1%) Request form ambiguity 3 (1.4%) Lack of quality control 4 (1.9%) Booking errors 9 (4.3%) Errors in internal or external systems 5 (2.4%) Use of nonoriginal request form 4 (1.9%) Other errors 21 (10.0%) Inadequate student/new-graduate supervision 6 (2.9%) Inadequate training 4 (1.9%) Exposure of staff or public to radiation 1 (0.5%) Spillage of radiopharmaceutical 10 (4.8%) Total 209 Category Recommendation Radiopharmacy training Provide extensive training for new staff members Radiopharmacy management Implement integrated software packages Radiopharmaceutical administration and dose Use coordinated approach in which all nuclear medicine professionals address administration and dose errors Pediatric dosing and weight estimation Use correct calculators and formulas Departmental protocols Provide in writing, regularly update, and keep readily accessible Education Teach TOP to all staff and audit for compliance Students/new graduates Improve supervision Error reporting Remove disincentives Safety Create culture of safety throughout department
