Public Release: 

New quality improvement system significantly reduces CT misadministration

Best practices protocol facilitates analysis, accountability, change

American Roentgen Ray Society

TORONTO, April 20, 2015--A protocol developed by radiologists at the Santa Clara Valley Medical Center reduced CT misadministration at the Santa Clara Valley Medical Center from 18 instances in 60,999 studies to zero in 36,608 in just 10 months. Misadministration includes, but is not limited to, imaging the wrong patient or body part without a physician's order or repeated imaging of a patient without a physician's order.

The best practices protocol includes several levels of assessment, including reverification checklists, workflow clarification, and individual accountability.

"CT misadministration is an important and actionable quality issue, particularly in light of growing public concern about radiation exposure," said Patrick Do, MD. "Our quality improvement analysis significantly reduced the rate of misadministration and potentially brings great benefits to patients, hospitals, and the public."

The study was featured in an electronic exhibit at the ARRS 2015 Annual Meeting in Toronto.

View the abstract

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