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Florida Patient Safety Corporation Near-Miss Reporting System Advisory for December 2007 Florida Patient Safety Corporation: December 2007 Advisory Contents 1. Introduction .............................................................................................. 1 Reporting of Near-Misses ............................................................................................1 The NMRS Continues to Experience Underreporting .............................................2 2. Risks Associated with Inappropriate Perioperative Anticoagulant Usage .......................................................................................................... 5 What Went Wrong in these Cases? ............................................................................8 A. Need for Improved Communication ...............................................................9 B. Provide Additional Education to Address Knowledge Deficit ......................9 C. Absence of Applicable Protocol .......................................................................9 D. Not Following Protocol .....................................................................................9 3. Errors Involving DVT Prophylaxis ...................................................... 12 The Dangers of DVT and Anticoagulants................................................................12 Develop Monitors to Measure Compliance with Protocols ....................................13 4. Failure to Update an EKG of a 90 Year Old Patient Prior to Surgery .................................................................................................... 15 What Factors Might Contribute to this Failure? ....................................................15 The Preoperative Checklist .......................................................................................16 Excerpted Portion of Preoperative Checklist ..........................................................17 5. Radiology Misreads “Caused” by Poor Quality of Images ................ 18 Radiology Risk ...........................................................................................................18 1 Florida Patient Safety Corporation: December 2007 Advisory 1 Introduction This is the fourth issue of the Florida Patient Safety Corporation NearMiss Reporting System Advisory (NMRS). Advisories provide an update on the project and discuss several near-miss reports received during the period since the previous Advisory. Commentary on the relevance of select near-misses from a patient safety perspective is also provided. Finally, we offer recommendations to reduce the potential for recurrence. Reporting of Near-Misses Reporting of near-misses continues to be difficult to achieve in the overwhelming majority of health facilities. The value of near-miss reporting has been well stated by the “pillars” of the patient safety community such as the Institute of Medicine, Joint Commission, and Institute for Healthcare Improvement, etc. As we move into 2008, we see an ever growing body of literature espousing the virtues of near-miss reporting. One recent example of the increasing importance being afforded to the concept of near-miss reporting importance occurred on November 13, 2007. On that date, the New York State Health Department and the New York Chapter of the American College of Physicians further legitimized the importance of reporting near-misses by jointly announcing an agreement to analyze "near-misses" in New York hospitals. In a threeyear demonstration program, the Health Department's Patient Safety Center will work with approximately 4700 doctors-in-training in internal medicine to confidentially collect and analyze "near-misses" to help hospitals build safer health care systems. This new system will complement New York's mandatory adverse event reporting system, New York Patient Occurrence Reporting and Tracking System (NYPORTS), 1 Florida Patient Safety Corporation: December 2007 Advisory which already collects information on serious injuries and deaths in hospitals. The now universally recognized benefits from reporting of near-miss events include the following:  Assists in understanding factors that prevent events from occurring  Identifies post-event lesson learned in a less stressful (no one was harmed)  Enables focus on improving problem processes, not only outcomes  Facilitates identification of problems at an early stage before they escalate  The causes of adverse events are generally the same as factors that cause near-misses. Thus, the yield from near-miss analysis is potentially equal to analyzing actual events The NMRS Continues to Experience Underreporting Unfortunately, reluctance to report near-misses remains the norm. The NMRS continues to receive far fewer reports than were originally estimated. Relatively speaking, a modest number of providers participate in the program. Most participants attribute this reluctance to report to already being overburdened with paperwork. This issue, compounded with the “if it didn’t happen, it doesn’t need to be reported” posture contributes to underreporting. Underreporting is especially disturbing when analyzing statistics compiled by the NMRS. Most near-miss categories reflect a continuing pattern: they are recurring and thus reflect mistakes that are repeated. In each Advisory, we publish data on “recurring” near-misses. As explained in previous Advisories, we pose the question “If this type of event occurred before, why do you think it has occurred again?” on each nearmiss report. Not infrequently, the response we receive to this question indicates “lack of a detailed follow-up or process for change”. An article titled “Closing the Loop on Recurring Near-Misses appeared in the 6/2007 Advisory. Data reflective of recurring near-miss reports in illustrated in the graph below. 2 Florida Patient Safety Corporation: December 2007 Advisory Recurring* Near-M isses (All Near-M isses) 100 89% 81% 75% 67% 62% 63% 51% 44% 33% 20% 19% 16% 12% 7% 6% 4% NA Blood/Blood Product s Clinical M anagement Falls NA M edical Devices/ Equipment / Propert y M edicat ions/ IV Fluids Ot her/M isc. Surgery Treat ment /Procedure/ Test s Yes Do Not Know No 4% 7% 64% 75 50 25 10 5 38% 23% 15% * Ref ers t o a Near-M iss t ype w hich has occurred previously in t hat f acilit y The types of near-misses we are receiving have not changed in terms of percentages. The majority of reports (63%) continue to reflect medication errors and treatment/procedure /tests. A previous article on medication errors appeared in the NMRS 3/2007 Advisory (Prevent Automated Drug Dispensing Cabinet Near-Misses). Two articles relating to anticoagulants appear in the current Advisory. Most of the treatment /procedure/tests near-misses relate to laboratory issues. An article relating to this problem, Preventing Patient Identification/ Specimen Labeling Errors appeared in the Advisory of 12/2006. Type of Near Misses – Near Misses to Date Near Misses Medications / IV Fluids Treatment / Procedure / Tests Other / Misc. Surgery Medical Devices / Equipment / Property Clinical Management Blood / Blood Products Falls Total Percentages 42% 21% 14% 8% 5% 5% 4% 1% 100.00% % Near-M isses Report ed 3 Florida Patient Safety Corporation: December 2007 Advisory The December 2007Advisory Content includes articles addressing the following issues:  Risks associated with inappropriate perioperative anticoagulant usage and errors involving DVT prophylaxis  Failure to verify the timeliness of an EKG  Radiology misreads “Caused” by poor quality of images The Florida Patient Safety Corporation is dedicated to continuously improving patient safety in the state by serving as a learning organization, assisting health care providers in enhancing the quality and safety of health care and reducing harm to patients, and working with a consortium of patient safety centers and other patient safety programs. Our Web site provides a single point of access to research and resources that will help promote excellence in health care in Florida. 4 Florida Patient Safety Corporation: December 2007 Advisory 2 Risks Associated with Inappropriate Perioperative Anticoagulant Usage We have received two near-miss reports involving patients admitted to an NMRS participant hospital for elective orthopedic surgery. In both cases, the anesthesiologist determined that an neuraxial anesthetic offered many advantages for this type of procedure and an epidural was chosen as the anesthetic technique. In the first case, five hours following an uneventful epidural anesthetic and surgical procedure, an order for the immediate administration of the anticoagulant Fondaparinux was written by the surgeon for deep vein thrombosis ( DVT) prophylaxis. The medication administration record (MAR) clearly displayed a warning to the effect that "Fondaparinux is not recommended for patients with an epidural". This warning was about to be ignored or overridden; a vial of Fondaparinux arrived at the bedside. At the last minute, the patient was prevented from receiving the drug by a diligent team member who double checked the MAR against the anesthesia record. In the second case, a patient already receiving low molecular weight heparin (LMWH) treatment on the hospital floor arrived in the operating room (OR) for an orthopedic procedure. No one on the OR team was, however, aware that she had received this drug. There is a well established literature that documents the risk of spinalepidural or spinal hematoma occurring in patients who receive LMWH or Fondaparinux around the time of epidural anesthesia. Typically, patients with spinal epidural hematoma experience a sudden severe pain at the level of hemorrhage, which may radiate to the limbs. A rapid development of neurological symptoms follows because of compression 5 Florida Patient Safety Corporation: December 2007 Advisory of the spinal cord. Motor and sensory deficits develop. The symptoms are usually progressive and may result in paralysis or even death.(2) Two potential scenarios, both involving communication failure must be considered and analyzed. These are:  The patient who has received DVT prophylaxis with LMWH or Fondaparainux , is admitted to the operating room and receives an epidural; it was unknown to the OR staff that the patient previously had an anticoagulant administered  The patient who receives an uneventful epidural and less than 12 hours later receives a dose of LMWH or Fondaparainux; it was unknown to the floor staff that the patient received an epidural in the OR Authoritative literature clearly indicates that spinal-epidural hematoma complicating epidural anesthesia, while unusual, has resulted in dire consequences including spinal cord ischemia and subsequent paralysis.(3) Such near-miss cases and their potentially catastrophic outcomes raise numerous questions as to how these events could have occurred. Additional questions include:  Why the choice of epidural anesthesia given the risk of spinal hematoma in a patient: --who has received DVT prophylaxis preoperatively? --who is about to receive DVT prophylaxis postoperatively?  Do these cases reflect knowledge deficit and if so with whom: – The surgeon for ordering the Fondaparinux shortly after surgery performed under epidural anesthesia? – The operating room nurse for being unaware that the drug was administered preoperatively? – The floor nurse for administering the drug postoperatively within a short time following the epidural? – The pharmacy for dispensing the contraindicated medication without first contacting the ordering physician? – The anesthesiologist for not knowing that the anticoagulant was ordered? – The hospital for not having more precise protocols in place to prevent these events? 6 Florida Patient Safety Corporation: December 2007 Advisory – The entire team for not being aware of the contraindications or important time intervals involving spinal/regional anesthesia and anticoagulants?  Are current organizational policies/procedures in place to prevent: – anticoagulated patients from receiving epidural/spinal anesthesia? – epidural/spinal anesthesia patients receiving anticoagulants? – patients who had recently undergone spinal-epidural anesthesia from receiving anticoagulants too soon post-operatively DVT prevention is one of the top safety priorities of the Agency for Healthcare Research and Quality (AHRQ) and the Joint Commission. As such, many institutions have developed guidelines for the use of anticoagulation in high-risk patients. Orthopedic surgery patients are a special focus of most guidelines, since they are at extremely high risk. Most commonly, low molecular weight heparin (LMWH) therapy is utilized to reduce the incidence of DVT in high risk patients. Fondaparinux is also used for this purpose but, as it is a new drug much less is known about it. In 1997, the FDA released a public health advisory (3) after more than 30 patients developed spinal hematoma subsequent to receiving LMWH around the time of epidural anesthesia, most commonly for orthopedic surgery. Salient aspects of the FDA Public Health Advisory report titled Reports of Epidural or Spinal Hematomas with the Concurrent use of Low Molecular Weight Heparin and Spinal-epidural Anesthesia or Spinal Puncture follow: 7 Florida Patient Safety Corporation: December 2007 Advisory In response to this serious patient safety issue, the American Society of Regional Anesthesia and Pain Medicine (ASRA) convened a Consensus Conference on neuraxial anesthesia and anticoagulation in April 2002(4). Conclusions from this conference regarding Anesthesia management of patients receiving LMWH include the following: Preoperative LMWH   Patients on preoperative LMWH thromboprophylaxis can be assumed to have altered coagulation. In these patients needle placement should occur at least 10-12 hours after the LMWH dose. Patients receiving higher (treatment) doses of LMWH, such as enoxaparin 1mg/kg every 12 hours, enoxaparin 1.5 mg/kg daily, dalteparin 120 U/kg every 12 hours, dalteparin 200 U/kg daily, or tinzaparin 175 U/kg daily will require delays of at least 24 hours to assure normal homeostasis at the time of needle insertion. Neuraxial techniques should be avoided in patients administered a dose of LMWH two hours preoperatively (general surgery patients), because needle placement would occur during peak anticoagulant activity.  Postoperative LMWH  Indwelling catheters should be removed prior to initiation of LMWH thromboprophylaxis. If a continuous technique is selected, the epidural catheter may be left indwelling overnight and removed the following day, with the first dose of LMWH administered at least 2 hours after catheter removal. Single daily dosing: the first postoperative LMWH dose should be administered 6-8 hours postoperatively. The second postoperative dose should occur no sooner than 24 hours after the first dose. Indwelling neuraxial catheters may be safely maintained. However, the catheter should be removed a minimum of 10-12 hours after the last dose of LMWH. Subsequent LMWH dosing should occur a minimum of 2 hours after catheter removal. Twice daily dosing: this may be associated with an increased risk of spinal hematoma. The first dose of LMWH should be administered no earlier than 24 hours postoperatively, regardless of anesthetic technique, and only in the presence of adequate (surgical) hemostasis.”   As such, the basis for NOT administering the Fondaparinux therapy at the time it was about to be given and the associated dangers are well documented in the literature. What Went Wrong in these Cases? The Department of Anesthesiology had taken a strong stance against the use of Fondaparinux in patients receiving epidural anesthesia. The basis for their concern was the possibility that the patient would receive Fondaparinux postoperatively despite having received a spinal or epidural anesthetic during the surgical procedure. Moreover, it was recognized that there is no antidote for Fondaparinux and no test to 8 Florida Patient Safety Corporation: December 2007 Advisory determine if a patient is at risk for a hematoma. In order to allay anesthesiologist concerns, a warning was preprinted on the MAR. This safeguard failed. Further investigation into causation factors are warranted in this case. Several questions must be answered to arrive at the root cause of this near miss. These include but are not limited to the following: A. Need for Improved Communication  Was the medication charted correctly?  Was the Orthopedic surgeon aware that the anesthesiologist was planning epidural anesthesia when prescribing the Fondaparinux?  As the Fondaparinux was about to be given too soon postoperatively, did this result from incomplete sign-out from the OR to the PACU?  Does Fondaparinux provide an advantage over LMWH that outweighs a possible increased risk as relates to hematoma? B. Provide Additional Education to Address Knowledge Deficit Perhaps the providers are not aware of the contraindication of concurrent use of LMWH and spinal-epidural puncture procedures. The need for education might entail training for all providers, with particular emphasis on the timing of LMWH or Fondaparinux therapy and the need for preoperative communication about the type of anesthesia. C. Absence of Applicable Protocol The facility did not have a clinical guideline to direct patient selection for epidural spinal anesthesia when receiving anticoagulation, conditions for holding anticoagulants, and conditions for removal of an epidural catheter.(5) D. Not Following Protocol 1. Conducting Medication Reconciliation; According to the Institute of Safe Medication Practices (ISMP), a complete medication list should include all drug names, doses, frequency of use, indications, and duration of use. This list should be reconciled at every transition in care or when new medications are prescribed. Breakdowns in the medication reconciliation process often result in team members without knowledge of what was or is to be administered. 9 Florida Patient Safety Corporation: December 2007 Advisory Initiation of medication reconciliation would have increased the potential that the near-miss would have been caught at an earlier point in the continuum 2. Computerized Medication Administration Record (MAR) Override The participant hospital initiated an important step by incorporating the MAR into a computerized system to decrease the potential for errors. One feature of the computerized MAR is its capability to communicate warnings for drug interactions, contraindications, pregnancy, adverse effects, over dosage, dispense message alerts, etc. that warn of user specific situations that have previously been problematic. In this event, the MAR reflected a clear warning regarding use of Fondaparinux. This warning was either ignored (overridden) or not seen by the staff member responsible for medication administration. The literature indicates that “override of warning” is a contributing factor for medication errors (6). In fact “workarounds” (circumventing the system’s safety advantages) have been associated with approximately 10% of medication errors associated with Bar-Code Medication Administration Systems. Regarding workarounds, one intervention that could potentially reduce errors is to require a supervisor’s explicit prioracknowledgement that an MAR warning is to be overridden. Another solution suggested in the literature is requiring a co-signer for high-risk medications, such as anticoagulants or pain medication thereby introducing a double check into the process. (1) Duffill J, Sparrow OC, Millar J, Barker CS. Can spontaneous spinal epidural haematoma be managed safely without operation? A report of four cases. J Neurol Neurosurg Psychiatry.2000;69:816-819. (2) Geets WH, Pineo GF, Heit JA ,et al. Prevention of venous throembolism: the Seventh ACCP Conference of Antithrombotic and Thrombolytic Therapy. Chest. 2004;126:3338S-400S. (3) Lumpkin MM. FDA Public Health Advisory [Food and Drug Administration Web site]. December 15, 1997. (4) Horlocker TT, Wedel DJ, Benzon H, et al. Regional anesthesia in the anticoagulated patient: defining the risks (the second ASRA 10 Florida Patient Safety Corporation: December 2007 Advisory Consensus Conference on Neuraxial Anesthesia and Anticoagulation). Reg Anesth Pain Med. 2003;28:172-97. (5) ISMP Medication Safety Alert!;Nurse Advice-ERR, December 2007,Vol 5, Issue 12. (6) The Joint Commission Journal on Quality and Patient Safety, Errors Prevented by and Associated with Bar-Code Medication Administration Systems; Cochran, Jones, et. al., May 2007, Volume 33, Number 5. 11 Florida Patient Safety Corporation: December 2007 Advisory 3 Errors Involving DVT Prophylaxis A recent near-miss report describes a situation where a morbidly obese patient with a history of deep vein thrombosis (DVT) was ordered low molecular weight heparin (LMWH) administered postoperatively. The patient did not receive the LMWH until three days postoperatively. In this case, “a diligent staff member identified and brought this omission to light after checking the medical record.” The reporter goes on to indicate in the “Suggestions” section of the report that “education/re-education of medical and nursing staff stressing statistics of DVT risk factors and incidence and benefits of prophylaxis” was warranted. The Dangers of DVT and Anticoagulants The above omission was potentially catastrophic and occurred because an order for a high risk medication fell through the cracks. It is well known that anticoagulants are classified as high-alert medications. Their misuse carries significant patient risk including serious injury or death. When used or omitted in error, anticoagulants can cause life-threatening or fatal bleeding events or thrombosis. The National Quality Forum (NQF) reports that more than 900,000 Americans suffer DVT annually and 500,000 of these persons develop pulmonary embolisms (PE) causing approximately 300,000 deaths. NQF indicates that this condition is the most common preventable cause of hospital death. Current estimates suggest that less than 50 percent of patients diagnosed and hospitalized with DVT received prophylaxis. (1) 12 Florida Patient Safety Corporation: December 2007 Advisory The Joint Commission(2) specifically cites anticoagulants as a high-alert medication group calling for enhanced safety through their 2008 National Patient Safety Goal 3E which requires hospitals to: “Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.” The Rationale for Requirement 3E is that “Anticoagulation is a high risk treatment, which commonly leads to adverse drug events due to the complexity of dosing these medications, monitoring their effects, and ensuring patient compliance with outpatient therapy. The use of standardized practices that include patient involvement can reduce the risk of adverse drug events associated with the use of heparin (unfractionated), low molecular weight heparin (LMWH), warfarin, and other anticoagulants.” Given the magnitude of the above cited anticoagulant related risk, hospitals are strongly encouraged to develop a formal strategy and protocols to address the prevention of thromboemboletic complications. These should minimally incorporate (a) early identification of patients at risk for developing DVT and (b) ensuring the initiation of appropriate prophylaxis. Develop Monitors to Measure Compliance with Protocols Once the above protocols are developed, the hospital should establish performance improvement monitors to measure compliance. Areas for monitoring might include the following: % of Patients Assessed for DVT Risk Measure the percentage of hospitalized adult patients (18 years and older) who are assessed for DVT risk within 24 hours of admission. % of Patient Confirmed for DVT Risk getting Pharmacological Treatment Measure the percentage of hospitalized adult patients (18 years and older) with risk for DVT who receive pharmacological prophylaxis treatment (unless contraindicated). (1) 13 Florida Patient Safety Corporation: December 2007 Advisory (1) National Consensus Standards for the Prevention and Care of Venous Thromboembolism (including Deep Vein Thrombosis and Pulmonary Embolism), National Quality Forum (2) http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals 14 Florida Patient Safety Corporation: December 2007 Advisory 4 Failure to Update an EKG of a 90 Year Old Patient Prior to Surgery The Near Miss Reporting System (NMRS) has received a report of an occurrence involving a 90 year old surgical patient arriving in the preoperative holding area. The report indicates that the patient had a history of irregular heart beat. The EKG was, however, outdated having been performed seven months earlier and prior to the onset of the irregular heartbeat. The report goes on to indicate that neither the nurses nor anesthesiologist noticed that the EKG was outdated. The patient was transported to the OR, sedated and the surgical procedure was performed. The patient tolerated the procedure well and was discharged. The outdated EKG was first noted postoperatively. Thus no assessment of Ischemia was performed preoperatively. The patient and hospital were fortunate in this instance. Given the patient’s age and cardiac history, the outcome might have been catastrophic. What Factors Might Contribute to this Failure? The typical preoperative environment is an exceedingly busy and complex setting. Staff is required to confirm and verify numerous processes, documents and other aspects to ensure that all are correct and that patient safety is, to the degree feasible assured. Presurgical activities that must be accounted for include but are not limited to:  History and physical exam is documented  Procedure on the surgical consent is consistent with the OR schedule 15 Florida Patient Safety Corporation: December 2007 Advisory  Surgical consent has been properly obtained  The consent form is signed and witnessed  The patient and/or family member verbalization coincides with the consent  The patient has been NPO for the proper time period  Allergies have been identified and noted  Identification band is present  Jewelry removed and secured  Dentures/prosthesis/contacts, etc. removed and secured  Prescribed preoperative medication given  Laboratory results are present  EKG are present  Preps are completed  Relevant images such as x-rays are present and properly labeled  Special equipment is available, present, and appropriately matched to the patient  The surgical site is properly marked  A “time out” has been conducted The Preoperative Checklist Many facilities make routine use of a preoperative checklist to confirm that the above items are present and all tasks performed. The majority of these checklists merely verify the presence or absence of an item; NOT whether it is current or not. Presence or absence is obvious and important. An easier to miss item is, however, the date a procedure was performed. If it's out-of-date, it's useless in a high risk patient. This is one area where a checklist configured with the “time sensitive” item correlated with the date performed (along with the corresponding requirement) would prompt staff to remember this occasionally overlooked aspect. The example below illustrates how this might be accomplished. The individual completing the preoperative checklist would indicate that each task has been completed or the proper form is on the chart by initializing the item. An N/A is placed in the column if item does not apply. 16 Florida Patient Safety Corporation: December 2007 Advisory Excerpted Portion of Preoperative Checklist Provider Initials 1. 2. 3. 4. 5. 6. 7. 8. History and Physical (within 30 days of procedure) CBC, Metabolic Panel, PT/PTT, UA within last 3 months EKG Report in chart (males >45/females>55; within last 6 months) CXR in chart Catheterization Report or Note in chart Operative Consent completed, signed (surgeon & patient), dated & witnessed Consent for blood transfusion Type and Cross for _______ units confirmed 1. ____________ 2. ____________ 3.____________ 4. ____________ 5. ____________ 6. ____________ 7. ____________ 8. ____________ 17 Florida Patient Safety Corporation: December 2007 Advisory 5 Radiology Misreads “Caused” by Poor Quality of Images Radiology Risk This article addresses three recently received near-misses involving incorrect radiological interpretations. Interpretation errors leading to misdiagnosis are, by far, the most prevalent radiology related misadventure. This is, moreover, an area of increasing concern from a medico legal perspective. Although historically viewed as a “low-risk” specialty, the medicolegal picture for radiology is changing. The Physician Insurance Association of America’s (PIAA) database compiled from 1985 to 2005 ranks radiology sixth in the frequency of claims reported as well as in the indemnity paid. The average radiology indemnity payment made during this period was 8.5 percent less than the overall average for all specialties ($180,148 versus $195,596). Radiology’s loss experience has deteriorated considerably in recent years, however. PIAA data show the average paid claims against radiologists increasing by one-third in a five-year time frame, from $257,984 in 2000 to $313,412 in 2005. “Errors in diagnosis”, especially malpractice cases alleging missed malignancies, is the most prevalent medical misadventure comprising more than 50% of overall claims in this specialty.(1) 18 Florida Patient Safety Corporation: December 2007 Advisory Near-Miss Case Background A NMRS participant hospital reportedly experienced three x-ray misreads all occurring on the same night. Each was the result of incorrect interpretations in conjunction with the provision of after hours coverage. All were near–misses discovered through subsequent consultant overreads. According to the hospital, the radiologist responsible for the incorrect interpretations cited poor quality of images as the primary causation factor for the misreads. The individual completing the near-miss report indicated in the “Changes Recommended” section of the near-miss report that radiologists should not attempt to make a diagnosis from poorquality examinations. If an image is of poor quality, the study must be redone or resent (in the case of teleradiology) prior to rendering an interpretation. We concur with this analysis. In circumstances where a pattern of poor imaging quality is suspected, an analysis should be undertaken to clarify the cause of this problem. The potential for poor-quality images increases due to a number of factors including but not limited to:        inappropriate views, type of imaging modality chosen, quality of image transmission (teleradiology) incorrect exposure, abnormalities outside the area of the primary examination, inappropriate imaging protocols, Incorrect/Inadequate imaging technique Once the types of problems are isolated, the determining factors will become clearer. Common causes may be linked to human factors such as staff being inadequately trained, too busy/fatigued or undertaking examinations without adequate clinical information. Radiologists may not be ensuring appropriate information is received prior to justifying an examination. As the severity from radiology misdiagnosis claims is increasing, it is vital that these issues be addressed from patient safety, risk management and performance improvement perspectives. Claims by 10 Most Prevalent Medical Misadventures: Radiology 19 Florida Patient Safety Corporation: December 2007 Advisory (1) PIAA, Radiology Risk Management Review 2005, Executive Summary pp ii-iv (2)Berlin, Leonard, Hindsight Bias: Malpractice Issues in Radiology, Department of Radiology, Rush North Shore Medical Center, American Journal of Roentgenology, 2000;175:597-601 (3)Goddard, Leslie, Jones, et al, Error in Radiology , British Journal of Radiology 74 (2001),949-951 Bristol Royal Infirmary, University of West of England 20