Patient misidentification and data integrity risks in ultrasound imaging: a case report using multi-framework incident analysis.

Abstract

Background: Digital imaging workflows depend on accurate scheduling, patient identity reconciliation, and reliable metadata continuity to ensure safe image storage and retrieval. Disruptions in these processes may not directly affect image acquisition but can delay access to imaging information and pose significant patient safety risks.

Objective: To examine a recurrent ultrasound workflow failure that compromised downstream image availability and to identify practical strategies for preventing recurrence.

Methods: A retrospectively reported ultrasound incident was examined using a structured case report approach. The event was analyzed using the International Classification for Patient Safety, the Health Information Technology Classification System, the 18-step medical imaging workflow model, a mini-root cause analysis, and a structured risk-control matrix. These complementary frameworks were integrated to classify the incident, localize workflow failures, identify causal mechanisms, and develop preventive and corrective strategies.

Results: The incident was classified as a health information technology-related technical and workflow failure with no confirmed patient harm but clear potential for delayed diagnosis and patient misidentification. The failure originated from missing bookings, modality worklist bypass, and manual patient identity entry, resulting in downstream interoperability failures that delayed image retrieval and interpretation. The mini-root cause analysis identified two interacting causal layers: execution-level workflow deviations and latent system vulnerabilities. Risk-control analysis demonstrated that recurrence was primarily driven by inadequate validation safeguards, weak workflow enforcement, and ineffective exception handling.

Conclusion: This case demonstrates that seemingly minor workflow deviations can evolve into clinically significant patient safety risks despite technically successful image acquisition. The integrated multi-framework analytical approach provides a practical method for identifying latent sociotechnical vulnerabilities, informing targeted risk-control strategies, and strengthening the safety and resilience of digital imaging workflows.