S YS T E M AT I C R E V I E W P R O T O C O L

Effectiveness of quality improvement interventions for

patient safety in radiology: a systematic review protocol
Shafiqur Rahman Jabin 1  Tim Schultz 2  Peter Hibbert 1  Catherine Mandel 3  William Runciman 1
1
Centre for Population Health Research, University of South Australia, Adelaide, South Australia, Australia, 2Centre for Evidence-based Practice
South Australia (CEPSA): a Joanna Briggs Institute Centre of Excellence, and 3Department of Radiology/Faculty of Medicine, Dentistry and Health
Sciences, University of Melbourne, Victoria, Australia

Review question/objective: The objective of this review is to find the best available evidence regarding
effectiveness of quality improvement interventions in clinical radiology and the experiences and perspectives of
staff and patients. More specifically, the review questions are:
 How effective are the interventions that may improve or affect patient safety and quality in clinical radiology?
 What are the experiences and perspectives of staff and patients of patient safety and quality
improvement interventions?
Keywords Diagnostic imaging; health information technology; healthcare professional; medical imaging;
patient safety

Background ‘‘Anesthesia’’ and ‘‘Critical and Emergency Care’’,

uality improvement is the term used to describe
Q the combined effort of healthcare pro-
fessionals, patients, their families, researchers,
payers, planners and academics to make changes
in three basic fields of health care: better patient
outcomes (health), better system performance (care)
and better professional development (learning).1
Patient safety, defined as the decrease of risk of
unnecessary harm associated with health care to
an acceptable minimum,2 is one dimension of the
quality of health care.3 Comprehensive quality and
practice improvement programs implemented across
radiology departments within hospitals have shown
some promise in improving quality and patient
safety.4-6 There are, however, comparatively few
interventions that are known to improve quality
and patient safety in radiology. Additionally, the
evidence base to guide quality improvement in radi-
ology is weak.7 For example, unlike many medical
disciplines and disease-based interest groups, such
as ‘‘Acute Respiratory Infections’’, ‘‘Airways’’,
Correspondence: Shafiqur Rahman Jabin,
rahmy027@mymail.unisa.edu.au
There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2016-003078
there is no Cochrane Review Group for Radiology.8
Radiology is heavily reliant on information tech-
nology (IT), helping to streamline a wide range of
operations and provide safe, effective solutions.
Health information technology (HIT) has emerged
as an indispensable tool of radiology that has been
employed widely in healthcare sectors and endorsed
as a remedy to many of the challenges faced by
imaging departments. Radiology IT systems such
as Picture Archiving and Communication Systems,
Radiology Information Systems and Computer-
aided diagnosis are used to enhance efficiency, effec-
tiveness and safety.9,10 Although such technology
has the potential to provide huge advantages for
healthcare delivery and patient outcomes, it can
affect patient safety and the quality of care, resulting
in patient harm due to inadequate planning, integ-
ration, training or testing.11-14
However, patient safety is difficult to quantify. It
may be measured as the number of patient safety
events, or ‘‘incidents’’, which are defined as an
event or circumstance, which could have resulted,
or did result, in unnecessary harm to a patient.2,15
Adverse events occur when patients are actually
harmed by their health care rather than an under-
lying disease.2 Known types of adverse events in
radiology include diagnostic errors16-19, transcrip-
tion errors in radiology reports20,21, infections22,

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SYSTEMATIC REVIEW PROTOCOL
adverse drug events23, wrong site, side, patient or
procedure24,25 complications26, falls27 and pressure
sores.28 Patient safety data may be shown through
incidents reported by healthcare professionals
and/or patients and carers, coroner’s reports,
medico-legal case files, medical records from private
facility and state-based public hospital.
Awareness of patient safety in radiology has risen
over the last decade through analysis of inci-
dents17,18,29 and by focusing on human factors6
and nontechnical skills (NTS).30 Human factors
are part of the scientific discipline dealing with
interactions among humans and other elements of
the system that optimize human wellbeing and over-
all system performance.31 Nontechnical skills are
cognitive, social and personal resource skills that
contribute to safe and efficient task performance.
They are essential to complement the technical skills
possessed by medical engineers, radiographers and
radiologists as situation awareness, decision making,
communication, teamwork and leadership are
incorporated with technical tasks.30 Communi-
cation failure and delayed diagnosis are the most
prevalent of these patient safety incident types in
radiology.32-39
Adverse events may also occur due to improper
human performance or failure to operate radiology
HIT, such as incorrectly requesting a study by refer-
rer, lack of rigor in performance by a radiographer or
misinterpreting a study by radiologist.40 Moreover,
radiologists may be given minimal training on the
use and operation of such systems41,42 or more
attention and concentration may be required to
perform new tasks, interventions and treatments
that are often not possible due to heavy workload
or deficiency in workforce.40,43,44 Radiology depart-
ments are required to address these risks in a timely
manner using principles of system resilience and
high-reliability organizations.14,15
The risks of adverse events may be overcome by
improving understanding of error,45 ensuring
appropriate criteria at the time of entry of patient
data,41 staff training,15,30 utilizing correct imaging
technique,46 adhering to as low as reasonably
achievable,44 proper integration of new HIT
systems,42-44,47 contingency planning and escalation
procedures,42 and configuration and communi-
cation between systems.14,48 In addition, healthcare
providers are urged to improve safety culture, which
has been considered as an important precursor for
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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
S.R. Jabin et al.
improving deficits in patient safety and thus may be
considered as a proxy for patient safety.49 Safety
culture has been measured using a number of tools
such as the Safety Attitudes Questionnaire (SAQ)
or Hospital Survey on Patient Safety Culture
(HSOPSC).49
Interventions to improve patient safety in
radiology have focused on several other areas. For
example, the implementation of new technologies
addressing human factors6 and systems deficits,
including technologies like patient identifi-
cation,50-52 voice recognition53-59 and web-based
solutions.60 Moreover, there has also been a demand
for general improvement in patient safety in radi-
ology focusing on various interventions such as
learning from error,61 using incident reporting sys-
tems,29,62 safety rounds,36 awareness and cognitive
behavior,63 clinical audit,64 clinical governance,65
teamwork and communication.66-68 A few studies
have also shown that the use of a pre-procedural
checklists69 or surgical safety checklists70 in radi-
ology improves communication and teamwork and
reduces adverse events.
However, critics of patient safety interventions,
such as those discussed previously, often claim that
they negatively impact on throughput of patients or
clinician workflow.71,72 A clearer understanding of
the possible negative impacts of patient safety inter-
ventions is required, and therefore, patient through-
put in radiology departments, and/or radiologist
workflow, will be included as secondary outcomes
in this systematic review. In addition, the success of
patient safety interventions is dependent on clini-
cian engagement73, therefore, knowing clinicians’
perceptions and experiences of the intervention is
essential to understanding why an intervention has
or has not worked. The use of both qualitative and
quantitative methods in patient safety research is
proposed to contextualize results.74 Consequently,
this systematic review will also include the qualita-
tive experiences and perceptions of staff and
patients.
The majority of previously cited studies examin-
ing interventions for improving patient safety in
radiology are of low quality and/or use a study
design that is prone to bias. To date, no compre-
hensive systematic review has been identified that
appraises quality improvement interventions in radi-
ology. The initial search looking for such systematic
reviews or systematic review protocols was
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SYSTEMATIC REVIEW PROTOCOL
conducted by the author during March 2015. Key
search terms utilized for this initial search included
radiology, medical imaging, patient safety, safety
and quality, and patient safety intervention. The
databases such as Cochrane Library, PROSPERO
and the JBI Database of Systematic Reviews and
Implementation Reports were searched accordingly.
Published reviews have addressed patient perspect-
ive of receiving care in medical imaging or radi-
ology75,76; however, there is an absence of reviews
on quality improvement interventions. The proposed
systematic review will provide comprehensive evi-
dence of quality improvement interventions in radi-
ology practice.
Inclusion criteria
Types of participants
The quantitative and qualitative components of this
review will consider studies that include patients
undergoing radiological examinations and/or
healthcare professionals (radiologists, radiogra-
phers, medical imaging nurses and other personnel)
working in hospitals or stand-alone healthcare facili-
ties or ‘‘super-clinics’’. ‘‘Super clinics’’ are healthcare
services with integrated multidisciplinary patient
care center, often including a general practitioner,
a provider of radiology and other allied health
providers.
Types of intervention(s)
The current review will evaluate the following types
of quality improvement interventions: human fac-
tors, HIT, training and education, staffing arrange-
ments (staffing levels, skill mix, grade mix and
qualification mix), regulation, incident reporting
and management, peer review (re-validation),
clinical audit, teamwork and communication inter-
ventions (e.g. TeamSTEPPS),77 safety checklists, loc-
al (clinical) governance and any other intervention
that meets the definition of quality improvement
interventions. Interventions that test the diagnostic
accuracy or performance of particular imaging
modalities or interventional radiology procedures
will be excluded from the review.
Phenomena of interest
For the qualitative component of the review, the
phenomena of interest are the experiences and
perspectives of staff and patients undergoing, or
being exposed to, the quality improvement
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©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
S.R. Jabin et al.
intervention. These experiences or perspectives
could include descriptions of safety concerns, the
context and culture of the workplace (including
factors such as conflict and how it is managed,
teamwork behaviors or the attitudes of staff to
patient safety), the management of adverse events
and near misses or changes to work practices. It is
anticipated that this data would be obtained from
interviews and/or focus groups with staff or patients
and, potentially, participant observations.
Context
The current systematic review will consider studies
that are based on a radiological setting.
Outcomes
The quantitative component of this review will con-
sider studies of ‘‘patient safety’’ outcomes including
adverse events and near misses (incidents), and any
validated quantitative measurement of safety culture
(such as the SAQ or HSOPSC tools).
The review will also include a number of secon-
dary outcomes. The first group of secondary out-
comes will be NTS including situation awareness,
decision making, communication, teamwork, lead-
ership, managing stress and coping with fatigue.30
Outcomes of NTS will be measured on the basis of
healthcare personnel’s command, control ability,
competence, simulation-based training, real-time
ratings, adaptability to healthcare settings and
others.78
Both patient throughput and clinician workflow,
objectively measured in terms of number of patients
treated in a defined time period by a defined number
of staff, will also be included as secondary outcomes.
The final secondary outcome will be radiology
patient satisfaction, which provides patients’
perspective on the quality of care.79
Types of studies
The quantitative component of this review will con-
sider Randomized Controlled Trials (RCTs) or Clus-
ter Randomized Controlled trials (CRCTs). In the
absence of RCTs or CRCTs, other experimental
study designs including non-randomized controlled
trials, quasi-experimental, controlled before after
trials and interrupted time series trials will also be
considered for inclusion.
The qualitative component of the review will
consider interpretive studies that focus on qualitative
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SYSTEMATIC REVIEW PROTOCOL
data including, but not limited to, designs such as
phenomenology, grounded theory and ethnography.
Mixed methods and descriptive studies will also
be included.
Search strategy
The search strategy aims to find published and
unpublished studies. A three-step search strategy
will be utilized in this review. An initial limited
search of EMBASE and MEDLINE (via Ovid)
will be undertaken followed by analysis of the text
words contained in the title and abstract, and of the
index terms used to describe article. A second search
using all identified keywords and index terms will
then be undertaken across all included databases.
Third, the reference list of all identified reports
and articles will be searched for additional studies.
Studies published in English will be considered for
inclusion in this review. Studies published from
1990 (when the first substantive patient safety
research study, ‘‘Harvard Medical Practice’’, was
published)80,81 onward will be considered for
inclusion in this review.
There is little published evidence on interven-
tions to improve patient safety in radiology.
Therefore, we have decided to keep the search
broad and focus on different types of interventions
that have been implemented with the intention
of improving patient safety as primary outcome
and other secondary outcomes as mentioned
above.
The databases for published studies to be searched
include EMBASE, MEDLINE, CINAHL, Cochrane
Central Register of Controlled Trials, PsycINFO and
Web of Science. The search for unpublished studies
will include Mednar, Trove, Google Grey and
OCLC WorldCat Dissertations and Theses.
Initial keywords to be used will be:
Radiology and its modalities: Radiology, diagnos-
tic imaging, medical imaging, clinical radiology, X-
Rays, computed tomography, angiography, mam-
mography, magnetic resonance imaging, ultrasound,
positron emission tomography, single photon emis-
sion computed tomography (Using OR Boolean
operator).
Populations: Healthcare professional, health per-
sonnel, radiologist, radiology nurse, radiographer,
radiology technician, radiology registrar, radiology
consultant, ultra-sonographer, patient, consumer,
private hospital, public hospital, stand-alone
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S.R. Jabin et al.
facility, super clinic, radiology department (using
OR Boolean operator).
Interventions: Health information technology,
picture archiving communication system, radiology
information system, computer aided diagnosis, voice
recognition technology, human factors, ergonomics,
human engineering, training, education, staffing
arrangement, incident reporting, peer review,
clinical audit, teamwork intervention, communi-
cation intervention, team training, safety checklist,
local governance, quality improvement intervention
(using OR Boolean operator).
Outcomes: Patient safety, incident, sentinel event,
event, near miss, adverse event, adverse incident,
safety incident, patient safety incident, event regis-
ter, safety culture, nontechnical skills, patient
throughput, workflow, patient experience, patients
perspective, staff experience, staff perspective (using
OR Boolean operator).
Types of studies: Randomized controlled trials,
cluster randomized controlled trials, quasi exper-
imental, controlled before and after trials, inter-
rupted time series analysis, grounded theory,
ethnography, phenomenology (using OR Boolean
operator).
Radiology and its modalities AND populations
AND interventions AND Outcomes AND Types of
studies. (using AND Boolean operator).
Assessment of methodological quality
Quantitative papers selected for retrieval will be
assessed by two independent reviewers for methodo-
logical validity prior to inclusion in the review using
standardized critical appraisal instruments from the
Joanna Briggs Institute Meta Analysis of Statistics
Assessment and Review Instrument (JBI-MAStARI)
(Appendix I). Any disagreements that arise between
the reviewers will be resolved through discussion or
with other reviewers.
Qualitative papers selected for retrieval will be
assessed by two independent reviewers for methodo-
logical validity prior to inclusion in the review using
standardized critical appraisal instruments from the
Joanna Briggs Institute Qualitative Assessment and
Review Instrument (JBI-QARI) (Appendix II). Any
disagreements that arise between the reviewers will
be resolved through discussion or with other
reviewers.
Critical appraisal will be conducted on these
papers. All papers will be included in the review.
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SYSTEMATIC REVIEW PROTOCOL
Where possible, sensitivity analysis will be con-
ducted to determine if methodological quality
impacts on the results of meta-analysis. The results
of higher quality papers (in which a score of 80% or
more is achieved in critical appraisal) will be com-
pared with lower quality papers (a score of less than
80% in critical appraisal).
Data extraction
Quantitative data will be extracted from papers
included in the review using the standardized data
extraction tool from JBI-MAStARI (Appendix III).
The data extracted will include specific details about
the interventions, populations, study methods and
outcomes of significance to the review question and
specific objectives.
Qualitative data will be extracted from papers
included in the review using the standardized data
extraction tool from JBI-QARI (Appendix IV). The
data extracted will include specific details about the
interventions, populations, study methods and out-
comes of significance to the review question and
specific objectives.
Data synthesis
Quantitative papers will, where possible, be pooled
in statistical meta-analysis using JBI-MAStARI. All
results will be subject to double data entry. Effect
sizes expressed as odds ratio (for categorical data)
and weighted mean differences (for continuous data)
and their 95% confidence intervals will be calculated
for analysis. Heterogeneity will be assessed statisti-
cally using the standard Chi-square and I-square.
Heterogeneity will also be explored using subgroup
analyses based on the different quantitative study
designs included in this review. Where statistical
pooling is not possible, the findings will be presented
in narrative form including tables and figures to aid
in data presentation where appropriate.
Qualitative research findings will, where possible,
be pooled using JBI-QARI. This will involve the
aggregation or synthesis of findings to generate a
set of statements that represent that aggregation,
through assembling the findings rated according to
their quality, and categorizing these findings on the
basis of similarity in meaning. These categories are
then subjected to a meta-synthesis to produce a
single comprehensive set of synthesized findings that
can be used as a basis for evidence-based practice.
JBI Database of Systematic Reviews and Implementation Reports
©2016 Joanna Briggs Institute. Unauthorized reproduction of this article is prohibited.
S.R. Jabin et al.
Where textual pooling is not possible, the findings
will be presented in narrative form.
Acknowledgements
The current review will contribute toward a PhD
degree from the University of South Australia for the
main author (SRJ).
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Appendix I: MAStARI critical appraisal instrument

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Appendix II: QARI appraisal instrument

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Appendix III: MAStARI data extraction instrument

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Appendix IV: QARI data extraction instrument

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