Abstract
With the aim of providing a clearer understanding of the tools used for evaluating risk in the radiological setting and how they are applied, this second part presents two practical examples. The first is a proactive analysis applied to CT, whereas the second is a reactive analysis performed following a sentinel event triggered by a CT study allocated to the wrong patient in the RIS-PACS system.
Riassunto
Al fine di una più chiara comprensione dell’applicazione delle modalità e degli strumenti di valutazione del rischio in ambito radiologico, in questa seconda parte vengono descritti due esempi pratici: il primo è costituito da un’analisi proattiva applicata alla procedura della TC, il secondo da un’analisi reattiva effettuata dopo un evento sentinella, scatenato da un’indagine TC erroneamente attribuita nel sistema RIS-PACS.
Similar content being viewed by others
References/Bibliografia
Reason J (2002) Combating omission errors through task analysis and good reminders. Qual Saf Health Care 11:40–44
Reason JT, Carthey J, de Leval MR (2001) Diagnosing “vulnerable system syndrome”: an essential prerequisite to effective risk management. Qual Health Care 10:21–25
Cattaneo M, Furlanetto L, Mastriforti C (1991) Manutenzione produttiva. L’esperienza del TPM in Italia. Isedi, Torino
Sicurezza dei pazienti e gestione del rischio clinico (2007) Ministero della Salute, FNOMCEO e IPASVI. Eds. Biblioteca la Professione www.salute.gov.it/imgs/c_17_pubblica zioni_640_allegato.pdf
Golfieri R, Fileni A, Centonze M et al (2008) Un vero evento sentinella in radiologia: il caso di Bologna. Riflessioni sulla professione di Radiologo. Il Radiologo 2:148–155
Sherman JL, Hartman DS, Friedman AC et al (1981) Angiomyolipoma: computed tomography-pathologic correlation of 17 cases. AJR Am J Roentgenol 137:1221–1226
Uhlenbrock D, Fischer C, Beyer HK (1988) Angiomyolipoma of the kidney. Acta Radiol 29:523–524
Wagner BJ, Wong-You-Cheong JJ, Davis CJ (1997) Adult renal hamartomas. RadioGraphics 17:155–169
Kim JK, Park SY, Shon JH et al (2004) Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at biphasic helical CT. Radiology 230:677–684
Pereira JM, Sirlin CB, Pinto PS et al (2005) CT and MR imaging of extrahepatic fatty masses of abdomen and pelvis: techniques, diagnosis, differential diagnosis, and pitfalls. RadioGraphics 25:69–85
Pedrosa I, Sun MR, Spencer M et al (2008) MR imaging of renal masses: correlation with findings at surgery and pathologic analysis. RadioGraphics 28:985–1003
http://www.gimbe.org/hot/appropriatezza/index.asp. Last access 01.07.2010
Van Breuseghem I, Geusens E (2006) Assessment of the appropriateness of requested radiological examinations for outpatients and the potential financial consequences of guideline application. JBR-BTR 89:8–11
The Project Perfect (2009) White paper collection: why it projects fail. www.projectperfect.com.au. Last access 01.07.2010
Archibald RD (1996) Project Management. La gestione di progetti e programmi complessi. Franco Angeli Ed., Roma
Coyle N, Sculco L (2003) Communication and the patient/physician relationship: a phenomenological inquiry. J Support Oncol 1:206–215
Evans WG, Tulsky JA, Back AL et al (2006) Communication at times of transitions: how to help patients cope with loss and re-define hope. Cancer J 12:417–424
Scally G, Donaldson LJ (1998) The NHS’s 50 anniversary. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ 4:61–65
Berlin L (2000) Liability of interpreting too many radiographs. AJR Am J Roentgenol 175:17–22
Gruppo di lavoro misto SIRM/SNR/SAGO/IMS (2006) Metodologia di determinazione dei volumi di attività e della produttività dei Medici Radiologi. Omicron, Genova
Halsted MJ, Froehle CM (2008) Design, implementation, and assessment of a radiology workflow management system. AJR Am J Roentgenol 191:321–327
Glaser C, Trumm C, Nissen-Meyer S et al (2005) Speech recognition: impact on workflow and report availability. Radiologe 45:735–742
Brant-Zawadski M (2008) Patientcentered radiology: use it or lose it. RSNA News 10-11
Berlin L (2007) Communicating results of all radiologic examinations directly to patients: has the time come? AJR Am J Roentgenol 189:1275–1282
Garvey CJ, Connolly S (2006) Radiology reporting-where does the radiologist’s duty end? Lancet 367:443–445
www.jointcommision.org
Mohr JJ, Batalden PB (2002) Improving safety on the front lines: the role of clinical microsystems. Qual Saf Health Care 11:45–50
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Centonze, M., Visconti, D., Doratiotto, S. et al. Clinical Risk Management in radiology. Part II: applied examples and concluding remarks. Radiol med 115, 1147–1164 (2010). https://doi.org/10.1007/s11547-010-0579-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11547-010-0579-z