Radiology version 6

RADIOLOGYRADIOLOGY

GENERAL COMMENTS

In 2018 there were 23 HCOs submitting data on the Radiology Clinical Indicators. There were no events in either interventional radiology or diagnostic radiology which were of the highest severity assessment code of SAC1. Although some events were reported as SAC2 (a lower risk event), the number of adverse events were low, reflecting high performance amongst the HCOs submitting data.

Extravasation during an intravenous contrast CT procedure is one of the risks when receiving contrast agents. The data from the submitting HCOs indicates that there is an increasing variability amongst the cohort, but the overall rate remains low. There is a large amount of case-mix risk with extravasation, so it is likely that these factors contribute to the variability within the set.

There were few organisations submitting data on image guided biopsy adverse events, which reflects the number of HCOs overall submitting data and that these procedures are generally performed in larger HCOs which see a more complex mix of patients.

Computed Tomography (CT) dosimetry is used to measure the dose index of radiation output from CT scanners. This measurement of output is to ensure that patients are not receiving too much radiation during their imaging procedures. This radiation dose should be within the reference levels in the National Diagnostic Reference Levels (NDRLs). The radiation dose has become an important element of continuous improvement with strategies to tailor CT scans to the patient. This is still an area for improvement with the aggregate rate of head CT exams and abdominal pelvic CT exams dosing above the NRDLs at 15.9% and 18.4% respectively. The identification of patients and their consent prior to procedures was excellent with all organisations having time-out procedures specific to radiological examinations; standardised processes in place to address correct patient, site and procedure; and through audit to demonstrate that the appropriate processes and procedures were followed prior to any procedure from the reporting organisations. This standardisation across institutions is encouraging and is a basic measure to reduce avoidable harm to patients.

Critical test result notification is a qualitative measure to determine if an organisation has in place measures to report any result or finding that may be considered life threatening or could result in severe morbidity requiring clinical attention. This measure was more variable than patient identification and consent but was generally well adhered to with the rates of procedures and policies in place at 91.3% and 89.5% respectively. This is an encouraging measure that supports quality improvement and better patient care within the healthcare organisation.

SUMMARY OF RESULTS

In 2018 there were 388 submissions from 23 HCOs for 9 CIs. None were analysed for trend. In 2018, significant stratum variation was observed in 1 CI. Three CIs showed greater systematic variation, with centile gains in excess of 50% of all events. Outlier gains in excess of 25% of all events were observed in 1 CI. See Summary of Indicator Results below.

Summary of Indicator Results

Indicator HCOs Aggregate rate %

Adverse Patient Events 1.1 Number of Severity Assessment Code (SAC) 1 or Incident Severity Rating (ISR) 1 incidents - interventional radiology examinations (L) 1.2 Number of Severity Assessment Code (SAC) 1 or Incident Severity Rating (ISR) 1 incidents - diagnostic radiology examinations (L) 1.3 Number of Severity Assessment Code (SAC) 2 or Incident Severity Rating (ISR) 2 incidents - interventional radiology examinations (L) 1.4 Number of Severity Assessment Code (SAC) 2 or Incident Severity Rating (ISR) 2 incidents - diagnostic radiology examinations (L) 17 0

20 0

17 0.013

20 0.002

1.5 Contrast extravasation during an IV contrast enhanced CT procedure (L) 20 0.274 1.6 Percutaneous trans pleural biopsy of lung or mediastinum requiring unexpected overnight admission (L) 1.7 Image-guided percutaneous core biopsy of liver requiring unexpected overnight admission (L) 9 1.46

9 0

# Number of undesirable or non-compliant events + % of events that contribute to outlier/centile gains * % of outlier HCOs

Best Stratum Outlier HCOS (%)* Outlier Gains (%)+ Centile Gains (%)+ Events# Trend

4

1 (5%) 3 (12%) 13 (52%) 25

2 (10%) 37 (10%) 166 (45%) 368

3 (33%) 9

RADIOLOGY RADIOLOGY

Summary of Indicator Results continued

Indicator HCOs Aggregate rate %

CT Dosimetry 2.1 CTDIvol for non-contrast CT head examinations (L) 15 15.9

2.2 CTDIvol for portal venous phase of abdominal pelvic CT examinations (L) 16 18.4 Patient identification and consent 3.1 Patient identification and consent (1) (H) 18 100 3.2 Patient identification and consent (2) (H) 14 100 3.3 Patient identification and consent (3) (H) 14 100 3.4 Patient identification and consent (4) (H) 1 100 Critical test result notification 4.1 Critical test result notification (1) (H) 14 91.3 4.2 Critical test result notification (2) (H) 10 89.5 4.3 Critical test result notification (3) (H) 10 78.9 4.4 Critical test result notification (4) (H) 1 100

# Number of undesirable or non-compliant events + % of events that contribute to outlier/centile gains * % of outlier HCOs

Best Stratum Outlier HCOS (%)* Outlier Gains (%)+ Centile Gains (%)+ Events# Trend

4 (27%) 79 (37%) 2 (13%) 54 (21%) 205 (95%) 216 195 (74%) 263