Publication Date


Type of Culminating Activity


Degree Title

Master of Science in Instructional and Performance Technology


Instructional and Performance Technology

Major Advisor

Seung Youn (Yonnie) Chyung, Ed.D.


The purpose of this research was to determine why there was a high number of errant radiology orders from requesting physicians at ATA Hospital. As the researcher, I wanted to clearly define errant orders, determine the root causes of errant orders, and further, make recommendations that would help diminish current as well as future order errors. This study answers three research questions: RQ1. Exactly what are the performance problems associated with errant orders within ATA Hospital’s radiology department that warrant further research? RQ2. What causes the increase in errant radiological orders at ATA Hospital? And, RQ3. What types of performance improvement solutions will reduce errant orders within ATA’s radiology department, while aligning with ATA Hospital’s budget and mission? By answering the three research questions, the performance gaps can be closed. In order to answer these questions, data collection specific to ATA Hospital and its performance problems had to take place.

Three major phases of data collection were facilitated for this study. The first phase consisted of open-ended interviews. The second phase consisted of exploratory, semi-structured observations. The third and final phase consolidated historical data collected over a four-month period from ATA’s out-patient imaging center and a three- month period from ATA’s main campus radiology department.

ATA Hospital has a high rate of errant ordered radiology exams. Based on research collected from ATA Hospital employees and physicians, and data analysis using Gilbert’s Behavior Engineering Model, the study identified four main factors that are the most probable root causes of errant ordered radiology exams. The first factor is a lack of data and not conveying feedback to physicians and support staff. The second factor is a lack of instruments, specifically a lack of consistency in radiology exam order sheets. The third factor is incentive or lack thereof by not providing positive or negative consequences when exams were properly ordered or errantly ordered, respectively. The last performance factor is related to knowledge, in that it is difficult for ordering physicians and radiology schedulers to keep up with changing exam protocols.

The recommendations from this study to decrease the amount of errant ordered radiology exams at ATA Hospital are to implement two short-term, paper-based solutions that will lay the groundwork for the third proposed long-term, electronic solution. The first short-term, paper-based solution – a quick reference order form – will be facilitated by current employees of ATA Hospital as well as feedback from physicians. The second short-term, paper-based solution – standardized exam order forms – will be standardized in format and nomenclature for ordering physicians both inside and outside the hospital. The third and long-term solution is a software-based exam order utility that will allow physicians to query exam and protocol questions, as well as directly order from a handheld device. The proposed software utility will utilize function, feedback, and format from the key stakeholders that used the short-term, paper-based job aids.