From Reactive to Proactive: Implementing a Low-Threshold Reporting System in a Large, Multisite Diagnostic Radiology Department

Presented at Radiology Society of North America 2017 Scientific Assembly and Annual Meeting December 1, 2017

Incident reporting is a key part of the foundation of safety, and its role in quality improvement (QI) in high-reliability industries such as commercial aviation and nuclear power is widely known. The Reason model of accident causation, also known as the swiss cheese model, posits that most system failures are latent errors, unsafe conditions which rely on safeguards in a subsequent process to prevent an adverse outcome. Although reports of adverse events and near-misses are effective for active errors, they often fail to capture latent system errors. High-reliability organizations are characterized by using proactive low-threshold reporting systems to decrease downstream failures. Low-threshold reporting has been shown in other health care subspecialties to improve the detection of latent errors. Although many diagnostic radiology practices have implemented root cause analyses and incident reporting for patient harms and near-misses, a paucity of literature exists on applying concepts of high-reliability in radiology. We present our initial experiences implementing a proactive program for low-threshold reporting by leveraging existing QI infrastructure within our large, multi-site academic and community radiology practice.