• Ronilda Lacson, Laila Cochon, Ivan Ip, Sonali Desai, Allen Kachalia, Jack Dennerlein, James Benneyan, and Ramin Khorasani.
• Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts. Electronic address: rlacson@partners.org.
• J Am Coll Radiol. 2019 Mar 1; 16 (3): 282-288.

PurposeThe aim of this study was to measure diagnostic imaging safety events reported to an electronic safety reporting system and assess steps at which they occurred within the diagnostic imaging workflow and contributing sociotechnical factors.MethodsThe authors evaluated all electronic safety reporting system reports related to diagnostic imaging during calendar year 2015 at an academic medical center with 50,000 admissions, 950,000 ambulatory visits, and 680,000 diagnostic imaging studies annually. Each report was assigned a harm score ranging from 0 to 4 by the reporter; scores of 2 (minor harm) to 4 (death) were classified as "potential harm." Two reviewers manually classified reports into steps involved in the diagnostic imaging chain and sociotechnical factors per the Systems Engineering Initiative for Patient Safety framework. The κ coefficient was used to measure interreviewer agreement on 10% of reports. The percentage of reports that could cause "potential harm" was compared for each step and sociotechnical factor using χ2 analysis.ResultsOf 11,570 safety reports submitted in 2015, 854 (7%) were related to diagnostic imaging. Although the most common step was imaging procedure (54% of reports), potential harm occurred more in result communication (odds ratio, 2.36; P = .05). Person factors most commonly contributed to safety reports (71%). Potential harm occurred more in safety reports that were related to tasks compared with person factors (odds ratio, 5.03; P < .0001). The κ coefficient was 0.79.ConclusionsSafety events were related to diagnostic imaging in 7% of reported events. Potential harm occurred primarily during imaging procedure and result communication. Safety events were attributed to multifactorial sociotechnical factors. Further work is necessary to decrease safety events related to diagnostic imaging.Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.

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