A case report of system configuration issue in medical imaging due to system upgrade – changes in hardware and software

Although the rapid growth in the efficiency of medical imaging is undeniable, the expansion of health information technology (HIT) into medical imaging has not been as seamless or well-integrated as it was thought to be. The socio-technical complexities in medical imaging associated with HIT systems can cause risks to patient harm and inconvenience, both individually and collectively, often in new, unforeseen, and unexpected ways. This study reflects a retrospectively collected single incident report related to medical imaging HIT systems, aiming to develop a set of preventive and corrective strategies. A combination of multiple deductive approaches (existing frameworks), i.e., HIT Classification Systems and 18-step medical imaging process workflow and inductive method (content analysis), were used to analyze the incident. The incident was identified as a “system configuration”-related software issue, contributed by system upgrade– changes in hardware and software. The incident was determined to occur during steps 10–12, i.e., “study selection and retrieval,” “calling up of patient's referral,” and “image review and interpretation,” causing severe disruptions in the clinical workflow for several weeks. We propose 16 preventive and corrective strategies grouped under four key areas based on the socio-technical aspects associated with HIT systems. The key areas are (i) preparation and integration for upgraded systems, (ii) training for medical imaging specialists, (iii) contingency planning/immediate backup system, and (iv) system design and configuration. These strategies are expected to help healthcare staff, analysts, reporters, researchers, and relevant stakeholders improve care delivery and patient safety in medical imaging in the context of any system upgrades.