Welcome to the Radiology Events Register (RaER)

The Radiology Events Register is a project funded by the Royal Australian and New Zealand College of Radiologists (RANZCR) Quality in Use in Diagnostic Imaging (QUDI) Program. The project is designed to undertake systematic data collection and analysis of adverse incidents and discrepancies in radiology to inform quality improvement and patient safety.

The QUDI Program is funded through a grant from Australian Government Department of Health Ageing (DoHA). For more information on the QUDI Program, please contact Jane Grimm.

In early 2006, QUDI commissioned the Australian Patient Safety Foundation (APSF) and Patient Safety International (PSI) to undertake the project. A number of institutions agreed to participate in a pilot project and the register went live in June 2006. Radiologists from these organisations were encouraged to report incidents and additional data was provided by medical defence organizations and through clinical review of adverse events.

By June 2008, over 650 incidents had been reported into RaER. These incidents were classified in a specially modified version of the AIMS software to allow for analysis of the underlying causes and contributing factors of an aggregated collection of radiological incidents with the aim of devising strategies to prevent re-occurrence. The report summarising the main findings of the pilot project found that:

The report summarising the main findings of the pilot project found that:

• Incident reporting systems require the full engagement of clinicians and professional bodies;
• Qualified privilege and security are required to encourage reporting of incidents;
• Incidents occurred most in X-ray (31%) CT scan (26%) and ultrasound (14%);
• Nearly 40% of incidents occurred during interpretation of images whereas 35% were detected during patient preparation;
• Staff, subject and organisational factors contributed to incidents in decreasing order of importance.

The RaER project continues in 2010-11. The focus of the project has now shifted to a greater focus on analysing and learning from incidents in the RaER database, while continuing to explore ways to improve incident reporting practices in medical imaging. Three clinical interest groups will be formed in mid 2010 to lead the analysis of RaER incidents to determine contributing factors and appropriate corrective strategies to improve safety and quality of medical imaging. The three incident types to be analysed are: (i) critical data sharing, (ii) clinical handover/takeover and (iii) diagnostic error. The results of the clinical interest groups' analysis will be submitted for publication in the peer-reviewed literature and presentation at an internationally significant conference/symposium.

Radiologists, radiographers and other disciplines involved in medical imaging are encouraged to report an incident anonymously into RaER.