Journal of the American College of Radiology
Volume 7, Issue 8 , Pages 593-602 , August 2010

Where Failures Occur in the Imaging Care Cycle: Lessons From the Radiology Events Register

Part of this research was presented as an oral scientific paper (SSC07) at the Radiological Society of North America conference in November 2009 (Chicago, Ill).

  • D. Neil Jones, BMBS

      Affiliations

    • Division of Medical Imaging, Flinders Medical Centre, Bedford Park, Australia
    • Human Factors Group, University of South Australia, Adelaide, Australia
    • Corresponding Author InformationCorresponding author and reprints: D. Neil Jones, BMBS, Flinders Medical Centre, Division of Medical Imaging, Level 2, Bedford Park, South Australia, 5042, Australia
    • ,
  • M.J.W. Thomas, BA, MEnvSt, PhD

      Affiliations

    • Human Factors Group, University of South Australia, Adelaide, Australia
    • ,
  • Catherine J. Mandel, MBBS

      Affiliations

    • Radiology Department, Peter MacCallum Cancer Centre, East Melbourne, Australia
    • ,
  • J. Grimm, BAppSc(Physio)

      Affiliations

    • Quality & Standards of Practice, Royal Australian and New Zealand College of Radiologists, Sydney, Australia
    • ,
  • N. Hannaford, RN, DipApplSc

      Affiliations

    • Australian Patient Safety Foundation, Adelaide, Australia
    • ,
  • Timothy J. Schultz, BSc(Hons), GradDiplPubHlth, PhD

      Affiliations

    • Australian Patient Safety Foundation, Adelaide, Australia
    • Discipline of Nursing, University of Adelaide, Adelaide, Australia
    • ,
  • William Runciman, MBBCh, PhD

      Affiliations

    • Human Factors Group, University of South Australia, Adelaide, Australia
    • Australian Patient Safety Foundation, Adelaide, Australia

References 

  1. World Health Organization. World Alliance for Patient Safety (The conceptual framework for the International Classification for Patient Safety; version 1.1: final technical report). Geneva, Switzerland: World Health Organization; 2009;
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  11. Royal Australian and New Zealand College of Radiologists. Closing the loop: diagnostic imaging communication in the emergency department. http://www.ranzcr.edu.au/qualityprograms/qudi/projects/qs.cfm#closingtheloopAccessed June 15, 2010
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  14. Cook RI, Woods DD, Miller C. A tale of two stories: contrasting views of patient safety. Chicago, Ill: National Patient Safety Foundation at the AMA; 1998;
  15. Knechtges PM, Carlos RC. The evolving role of radiologists within the health care system. J Am Coll Radiol. 2007;4:626–635
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  20. Norman DA. The psychology of everyday things. New York: Basic Books; 1988;
  21. Reason J. Human error. Cambridge, UK: Cambridge University Press; 1990;
  22. Hannaford N, Jones DN, Mandel C. The Radiology Events Register: final report. Adelaide: Australian Patient Safety Foundation; 2009;
  23. Hollnagel E, Nemeth CP, Dekker SWA. Resilience engineering perspectives: remaining sensitive to the possibility of failure. Aldershot, UK: Ashgate; 2008;
  24. Weick KE, Sutcliffe KM. Managing the unexpected: assuring high performance in the age of complexity. San Francisco, Calif: Jossey Bass; 2001;
  25. Shingo S. Zero quality control: source inspection and the poka-yoke system. Portland, OR: Productivity Press; 1986;

 This project was funded by the Quality Use of Diagnostic Imaging Program through the Royal Australian and New Zealand College of Radiologists (Sydney, Australia) and the Australian Government Department of Health and Ageing (Canberra, Australia).

PII: S1546-1440(10)00154-7

doi: 10.1016/j.jacr.2010.03.013

Journal of the American College of Radiology
Volume 7, Issue 8 , Pages 593-602 , August 2010

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