0:00

Most of us are aware that adverse events

0:04

and errors in radiology come in many forms.

0:08

Uh, as you review this slide, you will recognize many

0:12

of the common areas where errors

0:14

and adverse events take place.

0:16

And you will also recognize if you've been in the game long

0:19

enough that many errors, uh,

0:21

and actual adverse outcomes occur when more than one

0:26

of these, uh, areas of error kind of come together

0:30

in a Swiss cheese fashion.

0:32

Uh, whereby if any one thing had

0:37

gone differently, the adverse event would not have occurred.

0:41

But these, uh, these, these, uh,

0:43

these various different things, uh, add up, uh,

0:46

and ultimately lead to the adverse outcome.

0:49

Um, there are many,

0:51

many ways in this which can, in which this can happen.

0:54

And of course, uh, one

0:56

of the things they all have in common is

0:59

that they present very significant challenges, uh,

1:03

for those, uh, who must, who are tasked

1:06

with discussing these events with the patients

1:10

and families, which is one of the hardest conversations

1:14

that we can possibly have.