HospitalInspections.org

Based on document review and interview, it was determined the facility failed to analyze trends of all radiology incidents and misinterpretation of radiology studies and formulate and implement corrective actions to prevent recurrence of these events.

Findings include:

The document titled "Performance Improvement/Patient Safety Plan 2023-24" states, "since analyses of incidents and potential risks take place at all levels of the organization, there shall be education of professionals from across the organization in incident analysis, providing tools and expertise so that issues can be identified, and gaps in performance and the delivery of care can be addressed in a timely manner."

Review of a document titled "2023 Radiology Discrepancies Review," revealed there were 21 discrepancies of physicians' misreading of radiology studies. These discrepancies included fracture/subluxation, hip fracture and Pneumonia. There were 12 misinterpretations of fractures and five (5) discrepancies with interpretation of Pneumonia.
According to documentation on the 2023 Radiology Discrepancies, on 10/5/23, an Emergency Department physician misinterpreted a G-tube placement. The official read conducted on 10/6/23, revealed there was a possibly colon perforation.

The action taken on all discrepancies was "provider notified."

There was no evidence that all misinterpretations were analyzed, and gaps in performance and the delivery of care were not addressed in each event.

During interview with Staff B, Vice President Quality Management conducted on 2/2/24 at 3:45 PM, Staff B stated discrepancies of radiology studies is not an indicator, and these misreads are not discussed and analyzed in the Performance Improvement Coordinating Group Indicators meetings. Staff B also confirmed only three (3) of the 21 incidents had peer reviews.