Imaging intensive care patients: multidisciplinary conferences as a quality improvement initiative to reduce medical error

Insights into Imaging

Table 3 Quality management (QM) consequences

QM category	QM consequence	Number	Percentage (%)
Indication		8	5.8
	Consideration of feedback	5	62.5
	None apparent	2	25.0
	Untraceable	1	12.5
Procedure		25	18.0
	Repeat imaging	2	8.0
	None apparent	11	44.0
	Untraceable	12	48.0
Reporting		106	76.3
	Addendum to report	17	16.0
	Revision/retrospective adjustment	7	6.6
	None apparent (incl. persisting discrepancy)	17	16.0
	Untraceable	65	61.3

All examinations affected by QM events were retrieved from the patient record, and any consequences attributable to these QM events were documented. Consideration of feedback applies to indication-related QM events, e.g. request forms that were criticised for containing insufficient detail were followed by detailed and precise request forms for the next examinations. Repeat imaging concerns procedural QM events, after which patients underwent repeat-imaging following the correct protocol. Addendum to report refers to the creation of a separate report including the initially overlooked/misinterpreted finding, which was added to the original report. In revised/retrospectively adjusted reports, the original reports were edited to include the newly discovered/altered findings