Clarifying radiology's role in safety events: a 5-year retrospective common cause analysis of safety events at a pediatric hospital.
Hedieh KhalatbariSarah J MenasheRandolph K OttoAmy C HokeA Luana StanescuEzekiel J MaloneyRamesh S IyerPublished in: Pediatric radiology (2020)
Proposing and implementing solutions based on the analysis of a single safety event may not be a robust strategy for process improvement. Common cause analyses of safety events allow for a more robust understanding of system failures and have the potential to generate more specific process improvement strategies to prevent the reoccurrence of similar errors. Our analysis demonstrated that the most common system failure modes in safety events attributed to radiology were culture and process. However, the generalizability of these findings is limited given our small sample size. Aligning with other children's hospitals to use standard safety event terminology and shared databases will likely lead to greater clarity on radiology's direct and indirect contributions to patient harm.