Adverse events in medical imaging in Finland

Thesis event information

Date and time of the thesis defence

Place of the thesis defence

University hospital of Oulu

Topic of the dissertation

Adverse events in medical imaging in Finland

Doctoral candidate

Master of Health Science Tarja Tarkiainen

Faculty and unit

University of Oulu Graduate School, Faculty of Medicine, Research Unit of Medical Imaging, Physics and Technology

Subject of study

Medical physics and chemistry

Opponent

Professor Riitta Parkkola, University of Turku

Custos

Professor Jaakko Niinimäki, University hospital of Oulu

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Adverse events in medical imaging in Finland

Adverse events in medical imaging in Finland

There is a possibility of harm associated with all human activity. In healthcare settings, patient safety is an integral part of the quality of care. The risk of causing harm to a patient can be reduced by the careful planning of all procedures. The medical equipment used in imaging can cause various dangerous situations due to the radiation from the X-ray equipment or the force of an MRI magnet, as well as problems arising from using complex equipment with insufficient know-how. Radiation safety is regulated by law, and in Finland it is mandatory to report all adverse events in radiation safety to the Radiation and Nuclear Safety Authority. Patients can also report any injuries directly to the Patient Insurance Centre. Furthermore, the medical staff use various web-based tools for reporting incidents in patient safety to the authorities.

In this study, adverse events that occurred in Finnish imaging units as well as the reasons behind them were investigated by studying reports related to radiation use, patient injuries, and the electronic accident register. The study provided information on the frequency and severity of these adverse events as well as their risk factors. In addition, it provided information on the ways of preventing such events in imaging.

Based on this study, most of the abnormal events in X-ray practices reported to the Radiation and Nuclear Safety Authority were related to computed tomography (CT). Unnecessary or excessive radiation was mostly received by adult patients. The most common causes for radiation deviations were incorrectly selected examination programs, wrong areas of exposure, human or skill-related errors, incorrectly identified patients, and device-related malfunctions. Patient injury reports were most frequently associated with mammography, X-ray, and MRI examinations. Most of the patient reports were related to either delayed or incorrect diagnosis, and 30% of the injury reports were accepted with the patient receiving compensation. In addition to delayed, incorrect, or insufficient image interpretation (i.e. diagnosis), the patients were compensated for negligence in the examination or treatment process in cases where a more experienced staff member could have avoided this type of injury. The staff-reported adverse events occurred mainly during CT, X-ray, and MRI examinations. Three quarters (3 /4) of these reports were related to some degree of injury to a patient, while the rest were near misses. The risk for the patient was assessed to be minimal in most cases (85%) by supervisory staff.

The results from this study can be utilized in teaching the healthcare staff to observe and report any dangerous events more accurately. In addition, the results can be used in developing preventative measures to increase patient safety in imaging. At the moment, information about adverse events in imaging in fragmented, and the same information is being recorded in different places. In the future, there is a need for an electronic system that gathers all necessary information in one place and makes it accessible to all the professionals who need it.

Last updated: 24.10.2022