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Cited by 21Electronic Health Records SystemsPatient Safety and Medication ErrorsMedical Coding and Health Information

Identifying Clusters and Themes from Incidents Related to Health Information Technology in Medical Imaging as a Basis for Improvements in Practice

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Jabin, Md Shafiqur Rahman, Magrabi, Farah, Hibbert, Peter, Schultz, Tim, Runciman, William·2019·2019 IEEE International Conference on Imaging Systems and Techniques (IST)
DOI 10.1109/ist48021.2019.9010280
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Abstract

Beyond identifying and counting the things that go wrong, understanding how and why they go wrong requires qualitative research, especially for low-frequency events. The purpose of this study was to identify and characterize patient safety and quality issues related to health information technology (HIT) in medical imaging by collecting and analyzing incident reports through the lens of thematic analysis. In this article, we analyze 5 clusters: Staff related issues (16%), issues with diagnosis (15%), HIT incidents that involved “paper record” (12%), information and communication related (4%), and “action taken” related issues (4%). Human factors involved people failing to scan forms into the computer system (consents, requests, bookings, questionnaires, assessments, treatments and prescriptions), and another 4% involved failure to enter verbally imparted information into the system (about infectious patients, cancelled cases, and the status of reports). All of these problems had their genesis in human errors and violations. Human factors were found to cause more deleterious effects than technical factors. Of three instances of deaths caused by diagnostic issues, two were triggered by human factors, missed diagnosis. However, “staff or organizational outcome” was evenly distributed for both human and technical factors. It was therefore important to identify and characterize these incidents related to health information technology in medical imaging through the lens of thematic…

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  • The synthesis of findings across investigations, such as national thematic reviews, demonstrates the value of aggregating insights to identify recurrent patterns of risk that may not be apparent within single organisations.

    “The synthesis of findings across investigations, such as national thematic reviews, demonstrates the value of aggregating insights to identify recurrent patterns of risk that may not be apparent within single organisations (1, 63, 64).”

    From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [1]

  • As digital health infrastructures increasingly span organisational and sectoral boundaries, risks associated with design, configuration, and interoperability cannot be managed solely at the local level.

    “As digital health infrastructures increasingly span organisational and sectoral boundaries, risks associated with design, configuration, and interoperability cannot be managed solely at the local level (1, 42, 61).”

    From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [1]

  • An incident-driven approach has demonstrated the value of narrative synthesis for identifying recurring risk patterns that would be silent to purely statistical surveillance.

    “This aligns with an incident-driven approach, which has demonstrated the value of narrative synthesis for identifying recurring risk patterns that would be silent to purely statistical surveillance (1).”

    From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [1]

  • Digitisation redistributes responsibility across human and technical actors.

    “Digitisation redistributes responsibility across human and technical actors.”

    From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [1]

  • Sociotechnical theory highlights that HIT-related risk emerges from interactions across multiple system layers from user interfaces to organisational policies, vendor practices, and regulatory environments.

    “In contrast, sociotechnical theory highlights that HIT-related risk emerges from interactions across multiple system layers from user interfaces to organisational policies, vendor practices, and regulatory environments.”

    From Why digital health fails silently: a sociotechnical theory of health information technology–related risk (2026) · cites this paper as [1]

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Authors
Jabin, M. S. R., Magrabi, F., Hibbert, P., Schultz, T., & Runciman, W.
Affiliations
  • University of South Australia (AU)
  • Macquarie University (AU)
  • The University of Adelaide (AU)
ORCID
Venue
2019 IEEE International Conference on Imaging Systems and Techniques (IST)
Publisher
IEEE
Published
2019-12
Pages
1-6
DOI
10.1109/ist48021.2019.9010280
OpenAlex
W3007414692
Cited by
20
References
20
Citations by year
2026: 5 · 2025: 4 · 2024: 6 · 2023: 2 · 2022: 3
FWCI
0.85
Type
conference paper
Language
en
Open access
Licence
Locations
  • IEEE International Conference on Imaging Systems and Techniques (IST) (publishedVersion)
  • Adelaide Research & Scholarship (AR&S) (University of Adelaide) (submittedVersion, other-oa)
Topics
  • Health Sciences › Health Professions › Health Information Management › Electronic Health Records Systems
  • Health Sciences › Health Professions › Emergency Medical Services › Patient Safety and Medication Errors
  • Health Sciences › Health Professions › Health Information Management › Medical Coding and Health Information
Keywords
health information technology, diagnostic imaging, patient safety, incident reports, human factors, human error, missed diagnosis, paper records, electronic health records, quality of care, incident prevention, clinical practice improvement

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