Patient Safety Tip of the Week
October 22, 2013 How Safe Is Your Radiology Suite?
So just how safe is your Radiology suite? We’re not just talking about the risk of radiation to
your patients (though we will do a brief update on that at the end of today’s
column) or the risks of the radiological procedures themselves. And we are not
talking about diagnostic errors in interpreting imaging studies or failure to
adequately convey critical test results to the appropriate physician. We’re
talking about all the other potentially bad things that can happen to your
patients while they are in the Radiology suite. Things like falls, medication
errors, patient mixups, IV connection errors, running out of oxygen, conscious
sedation incidents, suicides, and others.
Falls
Many of our columns have highlighted the
radiology suite as a site where many patient safety issues occur (see our
Patient Safety Tips of the Week for October 16, 2007 “Radiology
as a Site at High-Risk for Medication Errors”, September 16, 2008 “More
on Radiology as a High Risk Area”, and October 7, 2008 “Lessons
from Falls....from Rehab Medicine” and our January 2010 What’s New in the Patient Safety World column “January
2010 Falls in the Radiology Suite”). In several of these we noted that radiology is an area where falls
often happen. Patients are often on a gurney or a table or in a wheelchair and
may fall when they attempt to get up to use the bathroom. They may be tethered
to IV poles or other equipment that become obstacles to trip over. And they may
have received benzodiazepines or other sedating medications for the radiology
procedure, further increasing their fall risk. So it is critical that the fall
risk of a patient is accurately conveyed to all staff when a patient is sent to
radiology. One way to facilitate such handoffs would be to include information
on fall risk in a structured communication tool for transports like the “ticket
to ride” we described in our
April 8, 2008 column “Oxygen
as a Medication”. The use of color-coded
wristbands continues to gain
momentum and may be used to identify patients at greater risk for falls.
Most of the literature has focused on
inpatients in the radiology suite. In one study of falls in a radiology
department (Abujudeh 2011) 80% of falls occurred in outpatients.
However, that reflected the relative proportion of radiological examinations
done on outpatients compared to inpatients. 44% of the falls were related to
the procedure being performed (eg. patient fall from an examination table). A
majority (72%) occurred while the patient was standing or ambulating and most
(61%) were unassisted falls. 85% had at least one known risk factor
predisposing to falls. Those who fell were more likely to be older, have
altered mental status, have a history of falls, and be taking antihypertensives
or CNS-acting medications. Though the overall rate of falls was low (0.46 per
10,000 imaging examinations), almost a third (29%) of the falls resulted in
injury. The likelihood of sustaining an injury related to the fall was
statistically significantly associated with ambulating at the time of the fall
and being on CNS-acting medications.
They recommend consideration of several
aspects to develop a fall reduction program in a radiology department. These
include adherence to assistance by staff, avoidance of walking in socks,
careful observation of surroundings, slow and steady mobilization, use of
eyeglasses, and use of extreme caution if using certain medications.
Though they didn’t go into details, 5% of the
falls in their study occurred in visitors. Since we can’t do the risk
assessments on visitors, that suggests we need to pay more attention to
environmental factors such as clutter, rug edges, etc. (see below).
The Pennsylvania Patient Safety
Authority reviewed its reports of serious events involving falls from 2005 to
2009 and found that falls accounted for 8% of reports from Radiology
departments (PPSA
2011a). They note that the interventions put in place on inpatient units to
prevent falls may not be replicated in patients transported to Radiology.
They found four themes that occurred in over
half the reports of falls in Radiology: syncope, slips/trips/loss of balance,
falls from stretchers or tables or stools, and medication-related events.
Cases involving syncope or near-syncope
accounted for 17% of reports. One factor implicated in some falls in Radiology
is fasting. They may have been fasting in preparation for a procedure. In
addition, other preparations for some procedures (eg. barium enema) may lead to
hypovolemia, predisposing patients to orthostatic hypotension. Remember, some
of the studies being done in Radiology require the patient to stand still in
the upright position, promoting orthostatic hypotension in vulnerable patients.
Others go from a supine position on a table or cart to the upright position for
transfer, similarly promoting orthostatic hypotension. And many patients are on
medications that have orthostatic hypotension as a side effect.
15% of their Radiology falls involved slips, trips or loss of balance. They note both use of walking aids (eg.
canes, walkers) and failure to use walking aids contributed to falls. They note
that patients are often left unattended in some areas of Radiology prone to
falls, such as bathrooms, dressing rooms, and waiting areas. They also noted
that patients’ clothing or footwear might become entangled with a variety of
equipment and other obstacles in Radiology.
Stretchers and tables are also commonly implicated (12% of
reports). Patients may fall from transport vehicles or from tables and chairs
being utilized for imaging studies. They note that sometimes patients on
gurneys or stretchers with siderails will crawl down to the end of the gurney,
resulting in tipping the gurney over and falling.
Medications, particularly those likely to impair mentation (eg. opiates and
benzodiazepines), were also commonly implicated in falls in Radiology.
Sometimes the medication was even given in Radiology (eg. sedation given for
claustrophobia before an MRI).
The PPSA study notes that Radiology staff
often do not participate in the falls risk training that inpatient staff
participate in. So they recommend educational and inservice interventions for
all Radiology staff to promote awareness of fall risk and measures to reduce
that risk. Transport personnel should be included in such training. Formal fall
risk assessments should be done on patients in Radiology. Whereas many
inpatients have had a fall risk assessment prior to going to Radiology, those
coming from the emergency department typically have not yet had a formal fall
risk assessment. Nor do most outpatients coming to Radiology for imaging
studies have fall risk assessments. The Pennsylvania Patient Safety
Authority has an excellent radiology falls risk assessment tool (PPSA
2011b). They also note the importance of involving patients and family in
increasing awareness of fall risk. Displaying a poster (eg. “Are you at risk
for falling?”) in the waiting area is one recommendation. We’ve previously noted the importance of
communicating fall risk in handoffs, particularly on the “Ticket to Ride” tool
often used for patients transported to Radiology. The PPSA echoes that
strategy. Remember also that patient transport is bidirectional. After a
patient has finished in Radiology there should be appropriate communication
back to the destination unit.
Environmental conditions obviously must be
dealt with to minimize falls. Many corridors in Radiology suites become
cluttered with equipment, transport vehicles, chairs, etc. Careful attention
must be paid to floor surfaces, rugs, and steps that may lead to patients
tripping and falling. Also floors may become slippery due to fluid leaks from
IV’s, incontinent patients, moisture brought in from outside on boots and
shoes, and other sources. We always look for such conditions when we do Patient
Safety Walk Rounds. But such walk rounds should become a daily exercise for
staff in the Radiology suite itself. Just as with falls on inpatient units,
many falls in Radiology occur in relation to patients using bathrooms so
special attention must be paid to them on such rounds. But just as important is
ensuring that there is staff available to help patients in Radiology use the
bathroom when necessary. Ensuring adequate lighting is also essential.
One frequently overlooked risk factor is
footwear. While we usually supply non-slip footwear for inpatients whom we
identify as being at high risk for falls, outpatients or ER patients are more
likely to be in socks or stockings that might promote falls.
Medication Errors
Our October 16, 2007 Patient Safety Tip of the Week “Radiology as a Site at High-Risk for Medication Errors” highlighted a United States Pharmacopeia (USP) MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services” (USP 2006). Though the overall number of medication errors in radiology areas was small, USP pointed out that the percentage of cases resulting in patient harm was considerably higher than seen with medication errors elsewhere. 12% of the medication errors in these areas were considered harmful to patients, about 7 times higher than the percentage in the overall MEDMARX® database. Using the Pareto principle, almost 80% of the errors fell into 4 types of error: improper dose/quantity, unauthorized/wrong drug, omission error, and wrong administration technique.
Many of the errors were attributable to problems outside the radiology department or had root causes outside the radiology department. This draws attention to a whole host of system issues that interplay to result in errors that happen to manifest themselves while a patient is in the radiology suite. Our July 31, 2007 Tip of the Week “Dangers of Neuromuscular Blocking Agents” gave an example of an incident where an emergency room resident inadvertently administered a neuromuscular blocking agent to a patient he had accompanied to the radiology suite for a CT scan. Obviously, that had little to do with “radiology” per se but does draw attention to potential high risk situations.
Below are some of the issues, conditions, and circumstances pertaining to radiology areas that may predispose patients to suffer medication (or other) errors:
- Patients often need to wait for tests or wait for transport back to their unit of origin. We have seen numerous examples of patients deteriorating while waiting for a procedure or waiting to be transported back after a procedure.
- Nursing care differs
from ICU.
While most radiology departments in large hospitals do have nursing staff dedicated to the radiology area, they may not have the same expertise or skill set that a nurse from an ICU might have. The nurse:patient ratio is usually not what one would have in the ICU. And even when a nurse from the ICU accompanies the patient to the radiology suite, that nurse may be unfamiliar with where medications or equipment are stored in the radiology department. - Lack of access to
current medication lists, allergy lists, etc.
While the patient’s chart usually accompanies him/her to the radiology suite, some important documents (eg. the MAR or medication administration record) may not. - The patient may be unable to give information and those who could answer questions are not available. The patient may have impaired cognition or impaired level of consciousness. He/she may have been pre-medicated prior to coming to radiology or may have received conscious sedation for a procedure. Typically (at least for an inpatient) a family member or caregiver or the housestaff, individuals who could provide vital information about a patient, may not be present in the radiology suite or otherwise readily available.
- The patients may be incredibly sick and have very complex medical problems, both of which are known to be associated with an increased likelihood of errors
- Sedation of patients for some procedures may have an additive effect to other medications (eg. narcotic analgesics) that a patient may be receiving.
- Some of the hi-tech patient safety technologies available elsewhere in a hospital may be unavailable or underutilized in radiology. This might include things like and electronic medical record (EMR), barcoding, electronic MAR, etc.
- Patients may arrive
with multiple lines and tubes.
Not only does this predispose to the rare occurrence of catheter misconnections, but often an IV must be temporarily discontinued and then there may be confusion as to how to restart that IV (especially for medications like anticoagulants). - Diabetic patients may represent specific problems. Particularly when a patient needs to spend a prolonged time in radiology, there may be confusion about insulin administration, meals, etc.
- Medications, supplies, equipment may have come from somewhere else. Particularly when medications have been brought with the patient from some other area of the hospital, there is often suboptimal documentation of dosage, time given, etc.
- Personnel in radiology may be unfamiliar with equipment. This may apply to items like infusion pumps. Often a hospital has pumps made by different manufacturers or different models used in different units of the hospital. Personnel in the radiology suite may not have experience with that particular model.
- Inadequate clinical
information.
The bane of the radiologist’s existence is the requisition lacking sufficient clinical information. How often does a requisition for an X-ray of the hip come down with “stroke” as the only clinical information! The radiologist needs to know what specifically is being looked for and other clinical information so that he/she knows what is the most appropriate study and can better interpret the result of the study. - Key people to communicate results to may not be readily available. The communication problem on the back end is as important as on the front end. We have talked in previous Tips of the Week about communication of critical reports back to physicians responsible for the care of the patient.
- Time pressures.
The time pressures to move patients through the radiology suite and accommodate not only inpatients but also outpatients and unscheduled cases can be enormous. Add to this staffing issues, particularly around nights and weekends and holidays. And financial pressures (eg. cost issues that lead to use of less expensive contrast agents in many patients).
Medication reconciliation and communication issues are two of the most important issues giving rise to medication errors in any setting, and from the above you can see that the radiology suite is no different. An article in the April 2006 American College of Physicians Observer, “Imaging hand-offs: Tips to help prevent medication errors” (Darves 2006) describes what the internist (or any physician with primary patient responsibility) can do to reduce the likelihood of medication errors relating to the radiology suite. In particular, that article addresses some of the issues related to interactions between certain medications and contrast agents (either directly or indirectly through effects on renal function). The importance of communication and defining roles (eg. who is responsible for followup actions) is stressed.
There are, of course, issues specific to radiology as well. These often pertain to use of contrast agents. This is especially likely to occur when there is inadequate information about previous allergies or renal function. There have also been numerous cases where the wrong type or wrong dosage of a contrast agent has been injected during myelography with disastrous results, often because of inadequate labeling or storage. And the issue of unlabeled syringes or basins is as big an issue in radiology as it is in the OR. Many remember an unfortunate case a few years ago where a patient was inadvertently given the antiseptic skin prep solution, chlorhexidine, instead of contrast media intraarterially (ISMP 2004).
The second major study on medication errors
in Radiology comes from the Pennsylvania Patient Safety Authority (PPSA
2009). They reviewed almost 1000 reports of medication errors from
Radiology services over a 5-year period. Errors related to contrast agents or
other agents used for imaging studies accounted for only about a quarter of the
events. Rather, the vast majority of medication errors were related to drugs
that are used throughout the hospital. Moreover, many of the leading drugs
involved were high-alert medications, like insulin, opioids, and
anticoagulants. Some involved moderate sedation being used for the imaging
procedure. The most common error types were wrong drug, dose omission, wrong
dose or overdose, and wrong rate. Drug omissions were particularly problematic.
They cite examples of infusions of insulin or heparin that were stopped for
prolonged periods while the patient was in Radiology leading to untoward consequences.
Almost 11% of reports involved problems with infusion pumps or IV lines. They
also noted errors related to patient information, with lack of concurrent
information about medications, lab values, patient weights, etc.
PPSA suggested several strategies to reduce
the risk of medication errors in Radiology including:
·
Review the
medication use processes in Radiology
·
Patient care
units sending patients to Radiology should carefully and proactively address
the plan of care for the patient while in Radiology, recognizing the
possibility any infusions may need to be stopped and how the therapy might be
affected by the length of the procedure in Radiology
·
Have nurses
specifically dedicated to Radiology or have nurses accompany the patient to
Radiology, particularly if they are on an infusion with a high-alert medication
·
Involve
radiology staff in training and competency evaluation and keep all in the loop
regarding medication safety issues
Because of the frequency of medication errors
in Radiology and fact that the errors often involve high-alert medications and
seriously ill patients, this is probably the patient safety consideration in
Radiology that merits the most attention.
Wrong Patient, Wrong Site, Wrong Test, etc.
More Tips to Prevent Wrong-Site SurgeryStahel 2010
The Pennsylvania Patient Safety Authority (PPSA 2011c) found in its database 652 events in 2009 of wrong procedure or test (50%), wrong patient (30%), wrong side (15%), and wrong site (5%) events occurring in Radiology settings.
Incorrect orders or requisition entries were
one of several root causes identified. As we’ve noted previously in our many
columns on wrong-site events, information coming from physicians’ offices may
contribute to the problem. Given the volume of imaging studies ordered, this
may be even more problematic for radiology than for surgery. Unfortunately, one
problem we continue to see is that the orders or requisitions for imaging
studies are often filled out by someone other than the physician (often a
nonclinical person) and inaccurate information appears on the requisitions.
This especially applies regarding the question about use of contrast. Other
errors might include the type of study. The PPSA study noted that for
mammography there were considerable errors in ordering screening vs. diagnostic
mammograms. Also, since some imaging studies get ordered on paper requisitions
(or simply on prescription forms) illegible handwriting remains a problem.
Failure to confirm patient identity is
another major root cause. To comply with Joint Commission standards all
facilities must use at least 2 forms of identification for all procedures,
including imaging studies. Moreover, such identification must be active rather
than passive. It is not acceptable to even ask a patient “Are you Mary Jones?”.
You must ask the patient to say their full name. Most facilities use the date
of birth as the second form of identification so the patient should be asked to
say their date of birth aloud. The PPSA study had numerous examples of the
wrong patient responding to a call in the waiting room and subsequently getting
the wrong study. There were also examples of transport services bringing the
wrong patient but the correct chart to the Radiology suite. Especially
problematic are cases where the room of a patient has changed and someone
wrongly assumes they have the original patient (remember, Joint Commission does
not allow room number or location to be an identifying item). Also, don’t forget
that it is common to have names that sound alike or even names that are
identical.
Failure to follow site and procedure
verification or procedure qualification processes was the other major root
cause in the PPSA study. One error we’ve previously mentioned for wrong-site
procedures is actually being misled by the patient. The PPSA study had examples
of a radiology technologist listening to the patient’s symptoms and thinking
the exam was for a specific body part when, in fact, the physician was
interested in an exam of a totally different body part. But this category also
included inadequate screening (for instance failure to screen for implants,
etc. before an MRI, failure to screen for pregnancy, failure to look for renal
dysfunction prior to use of contrast, etc.).
PPSA notes that failed communication really
contributes to all three of the above root causes and notes the need for
programs that improve communication, team work and safety culture. But they
also note the importance of using the Joint Commission Universal
Protocol for imaging procedures and actually provide a nice Radiology Services
Patient and Procedure Identification Assessment tool (PPSA
2011d) to help. The paper also provides multiple other strategies you
should consider.
We’d also like to
mention that use of patient photographs may have a valuable role, not only in
avoiding wrong patient issues but also in improving radiologists’
interpretation of images. See our April
30, 2013 Patient Safety Tip of the Week “Photographic
Identification to Prevent Errors” for examples of use of patient
photographs to identify wrong-patient cases in radiology.
Later in today’s
column we also mention two tools that are modifications of the WHO Surgical
Safety Checklist, modified for interventional radiological procedures. The WHO
Surgical Safety Checklist: for Radiological Interventions ONLY checklist is
downloadable here.
A second safety checklist for interventional radiological procedures, modeled
after the WHO Surgical Safety Checklist, appears in a recent article by
Canadian radiologists (Athreya
2013).
Moderate/Conscious Sedation
Moderate sedation (also formerly known as
conscious sedation) is utilized in many procedures performed in the Radiology
suite or MRI suite. The physicians must be credentialed to do moderate sedation
and the nursing staff have up-to-date competencies in moderate sedation.
Appropriate equipment for resuscitation needs to be immediately available.
Identification of patients at high risk (eg. those with COPD or sleep apnea or
certain neuromuscular disorders) is important and an anesthesiologist’s
presence might be required for such patients. Monitoring of patients is
crucial, particularly since different patients react differently to the same
doses of various agents used in sedation. In addition to monitoring vital
signs, level of consciousness, and pulse oximetry, there has been an increasing
trend to also use capnography for monitoring.
But in addition to the procedure and moderate
sedation itself, keep in mind that these patients may be at increased risk for
falls for some time after the procedure.
Problems with oxygenation
Some seriously ill patients need imaging
studies and many of these can only be done in the Radiology suite. Hence it’s
not uncommon to have patients on oxygen or even on mechanical ventilation in
the Radiology suite. Unexpected extubations may occur in Radiology. We’ve also
mentioned previously that “Ticket
to Ride” handoff tools arose
primarily because previous studies showed that half of ICU patients transported
to Radiology ran out of oxygen at some point.
The old literature also cites instances where
wall-mounted gas lines were transposed. However, we expect that all facilities
have addressed the issue and taken steps to prevent inadvertent misconnection
to wall-mounted gas sockets.
IV errors
We discussed many errors related to IV lines
in the section above on medication errors. These include things like stopping
IV infusions for a procedure and forgetting to restart them, misprogramming of
infusion pumps, patients getting the wrong drugs, etc.
But the PPSA study on medication errors in
Radiology also notes tubing misconnection errors. They describe one case where
contrast and saline were injected into a tracheostomy cuff rather than an IV
line (the connectors apparently looked similar).
Suicides in the Radiology Suite
We have previously done several columns on preventing suicides in hospitals:
· January 6, 2009 “Preventing Inpatient Suicides”
· February 9, 2010 “More on Preventing Inpatient Suicides”
·
December 2010 “Joint
Commission Sentinel Event Alert on Suicide Risk Outside Psych Units”
We encourage you to
read those columns since they have many practical considerations. You need to
be especially cognizant of the risks when patients go elsewhere in your
facility. An AHRQ
WebM&M Case & Commentary several years ago noted a suicide attempt occurred in a bathroom in
the radiology suite. We wonder how many hospitals would have inspected that
bathroom for potential suicide risk. We’ve done that in several hospitals and
uniformly found that not only do those bathrooms have numerous “loopable” items
that could be used for hanging but also that they can be locked from the inside
and there is typically no one readily available with a key to get in. In fact,
that is one of the items we added to our patient safety scavenger hunt list
(see our March 16, 2010 Patient Safety Tip of the Week “A
Patient Safety Scavenger Hunt”). Bathrooms on non-psychiatric floors may be
especially problem prone. Not only are they seldom assessed for tools and
implements that could be used for suicide, but some also allow the door to be
locked from the inside. So observation protocols for potentially suicidal
patients on such units should ensure that doors are not locked (or, if they can
be locked, that the “observer” has keys to access the bathroom). Having
observers of the same gender as the patient also is recommended.
Communication of suicide risk to all parties is particularly important during transports within the hospital (such as going to the radiology suite). Your “Ticket to Ride” handoff tool for hospital transports should also be used to properly prepare for potentially suicidal patients.
Some patients may come to Radiology with a known suicide risk. But sometimes patients may present first to Radiology for a procedure and staff there may identify the patient as being at risk for suicide. Radiology staff therefore need to be aware of identifying patients at risk for suicide and know what interventions to take. A recent article (Penzias 2013) and a related story board are good resources to review on this issue.
Infection Risks
Some procedures done in the Radiology suite (invasive procedures, insertion of catheters, etc.) must be done under sterile conditions and require good technique and adherence to good practices such as, for example, use of the central line insertion checklist.
But the Radiology suite is visited regularly by patients with all sorts of infectious illnesses, many with multidrug-resistant organisms. In addition, we are seeing more and more MRSA and C. diff infections in the community so outpatients with these infections are also visiting the Radiology suite.
So not only is strict adherence to hand hygiene guidelines important but you need to be working with your infection control personnel to ensure that other appropriate precautions are taken and that equipment, examination tables, etc. get appropriate disinfection.
Pregnancy
Pressure-Related Injuries
Because patients may be in the Radiology suite for prolonged periods (either for prolonged procedures or simply waiting for a procedure or for transport) some may become vulnerable to pressure-related injuries (eg. decubiti, compressive neuropathies) if attention is not paid to repositioning. There should always be a plan in place for overall nursing care of any patient sent to the Radiology area.
Patients Deteriorating During Prolonged Waits in Radiology
Patients often need to wait for tests or wait for transport back to their unit of origin. We have seen numerous examples of patients deteriorating while waiting for a procedure or waiting to be transported back after a procedure. Sometimes this is related to omission of critical medications like insulin or anticoagulants or antibiotics (see the section above on medication errors in the Radiology suite). Other times it may be related to inadequate monitoring (eg. patients on PCA or opioids via other routes).
Our March 13, 2012 Patient Safety Tip of the Week “Medical Emergency Team Calls to Radiology” highlighted a series of papers by Lora K. Ott and colleagues (Ott 2012, Ott 2011a, Ott 2011b) on events in the Radiology suite that required medical emergency team calls. The nature of the events in the radiology suite were primarily cardiac in 41%, respiratory in 29%, and neurological in 25% and most required a higher level of care after the event. 44% of the calls involved patients undergoing CT scan and 22% MRI scanning. That should not be surprising, given our many prior articles on safety issues in the radiology suite. During either procedure the patient is relatively isolated from monitoring staff for periods of time. In addition, sedation may be used to facilitate completion of some of those studies. Dislodging of catheters, tubes and lines during transfer to the CT/MRI platforms could also play a role. Also, the nature of the underlying condition necessitating the CT or MRI scan may also predispose these patients to the types of deterioration seen.
Transport of ICU patients to the radiology suite has for a long time been known to be hazardous. In our September 16, 2008 Patient Safety Tip of the Week “More on Radiology as a High Risk Area” we noted a paper by Smith et al (Smith 1990) which reported adverse events during 34% of all ICU transports. Specifically, transport of ICU patients to the CT suite was associated with a 71% incidence of adverse events. Adverse events included disconnection of monitoring equipment, interruption of vasoactive medication drips, unintentional extubations, etc.
So that brings us
back to another of our favorite topics – the handoff. In our February
14, 2012 Patient Safety Tip of the Week “Handoffs
– More Than Battle of the Mnemonics” we discussed how the structure and
format of handoffs needs to be tailored to the specific situation. The “Ticket
to Ride” concept (see our Patient Safety Tips of the Week for April 8, 2008
“Oxygen
as a Medication” and November 18, 2008 “Ticket
to Ride: Checklist, Form, or Decision Scorecard?”) is a tool ideally
suited for the radiology suite. It was originally developed for patients on
oxygen therapy needing transport to radiology since studies had shown over 50%
of such transports resulted in patients running out of oxygen. However, this
concept addressing handoffs has been expanded to include attention to
medication management, suicide risk, wandering risk, etc. in patients
transported to radiology or other sites within the hospital. Our March 13, 2012
Patient Safety Tip of the Week “Medical
Emergency Team Calls to Radiology” has some good suggestions about what
should be included in your “Ticket to Ride” transport handoff tool.
This really fits into the concept of having a well thought out plan before sending patients to the Radiology suite. We must anticipate what sorts of problems the patients might encounter and take steps to mitigate the risks of those problems.
Contrast-Related Events
There are, of course, issues specific to radiology as well. These often pertain to use of contrast agents. This is especially likely to occur when there is inadequate information about previous allergies or renal function. Sometimes patients cannot provide the information about their other medications (eg. metformin) or whether they have an allergy to contrast, or whether they have impaired renal function. Hence it is critical to review the medical record for these issues and appropriately assess labs to ensure that results of current tests of renal function are available.
There have also been numerous cases where the wrong type or wrong dosage of a contrast agent has been injected during myelography with disastrous results, often because of inadequate labeling or storage. And we noted above the issue of unlabeled syringes or basins is as big an issue in radiology as it is in the OR such as the unfortunate case a few years ago where a patient was inadvertently given the antiseptic skin prep solution, chlorhexidine, instead of contrast media intraarterially (ISMP 2004).
Mishandling or Mislabeling of Specimens
More and more biopsy and tissue specimens are coming from the Radiology suite rather than the OR these days. Such specimens are prone to a variety of errors in mishandling, mislabeling, switched specimens, or simply lost specimens. For insight into some of the issues around such errors see some of our other columns on errors related to laboratory studies:
- October 9, 2007 “Errors in the Laboratory“
- November 16, 2010 “Lost Lab Specimens”
- October 11, 2011 “LEAN in the Lab”
- March 6, 2012 ““Lab” Error”
- April 2012 “Specimen
Labeling Errors”
MRI Safety
Safety in the MRI unit is a whole topic unto its own. We refer you to our prior columns on patient safety issues related to MRI:
·
February 19, 2008 “MRI
Safety”
- March 17, 2009 “More on MRI Safety”
- October 2008 “Preventing Infection in MRI”
- March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
- February 1, 2011 “MRI Safety Audit”
- October 25, 2011 “Renewed Focus on MRI Safety”
- August 2012 “Newest MRI Hazard: Ingested Magnets”
The only additional recent study related to MRI safety we’d like to note is one that used a ferromagnetic detection system to detect implants and other objects (Shellock 2013). This system has the potential to be used in screening of patients prior to MRI.
Radiation Hazard to Patients
Though not the focus of today’s column, we have done numerous columns on the issues related to the safety hazards of ionizing radiation (see the list at the end of today’s column). But there have been several recent developments regarding reducing the dose of ionizing radiation and thus reducing the potential downstream risk of cancer. Researchers at Johns Hopkins (Pindrik 2013) found that limited-sequence head CT scanning provided adequate and accurate diagnostic information in children with shunted hydrocephalus. They were able to demonstrate that consistent sequences of 7 CT slices (instead of the typical 30-40 slices taken) were able to demonstrate the diagnostic information needed. This resulted in a 92% reduction of radiation dose. Use of this type of thinking should be applied to many other CT procedures to determine how many and which slices are necessary for adequate diagnosis.
Another paper (John 2013) reported on a checklist for pediatric digital radiography safety as part of the Image Gently® campaign. The checklist was developed to help radiology technologists obtain digital radiographs with patient safety in mind. Today not only CT scanning but most imaging uses digital techniques. With digital techniques radiology technologists no longer have the ability to visually determine whether there was overexposure or underexposure like they could in the old film screen world. New grads may be familiar with the new image technologies but older technologists may not. So the checklist and companion educational tools were developed and piloted. The actual checklist is included in the article or is separately downloadable from the Image Gently® website. The latter has great resources on its Image Gently and Digital Radiography - Quality Improvement page, including links to the Digital Radiography Safety Checklist itself and the implementation manual. The checklist can also be used as a quality improvement audit tool. The Image Gently® website also has a downloadable spreadsheet tool for data collection to be used in your quality improvement activities. Note that the John paper also has a good discussion on checklist design (do-and-verify vs. read-and-do, keep it short, include only critical steps, etc.).
Our June 2010 What’s New in the Patient Safety World column “WHO Checklist for Radiological Interventions” highlighted a checklist developed specifically for radiological interventions. That WHO Surgical Safety Checklist: for Radiological Interventions ONLY checklist is downloadable here. Meanwhile, a group of Canadian interventional radiologists (Athreya 2013) developed their own safety checklist for interventional radiological procedures, modeled after the WHO Surgical Safety Checklist. Note that their checklist also includes items that the ward to which the patient is being transferred has been notified and that aftercare instructions have been communicated to the patient. The checklist is scanned into the medical record after the procedure and can be utilized for quality improvement audits as well. They note the importance of regular review and revision of the tool. Such review led to a revision that made review of any prior imaging necessary (note our Patient Safety Tips of the Week for August 27, 2013 “Lessons on Wrong-Site Surgery” and January 1, 2013 “Don’t Throw Away Those View Boxes Yet” discussed the importance of reviewing imaging studies in avoiding wrong site surgery).
On the adult side, Image Wisely® has begun to present the Image Wisely Radiation Safety Case, a series of free online and mobile-compatible educational offerings in conjunction with the American College of Radiology (ACR). They plan to run six radiation safety cases over a year.
Also, this month’s AHRQ Web M&M has two columns pertinent to the issues of balancing risks vs. benefits when considering diagnostic imaging that uses ionizing radiation. One is an excellent interview (Wachter 2013) with Rebecca Smith-Bindman, MD, whose work on reducing unnecessary exposure to ionizing radiation we have mentioned in several of our prior columns. The other is a perspective by Italian radiologist Antonio Pinto (Pinto 2013)
We bet you never thought what a potentially dangerous area the Radiology suite can be! The Radiology suite is a great place to include in your Patient Safety Walk Rounds and an excellent place to choose for doing a FMEA (Failure Mode and Effects Analysis) exercise.
Some of our prior columns on patient safety issues in the radiology suite:
· October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
· September 16, 2008 “More on Radiology as a High Risk Area”
·
October 7, 2008 “Lessons
from Falls....from Rehab Medicine”
·
January 2010 “Falls
in the Radiology Suite”
·
August 2010 “Sedation
Costs for Pediatric MRI”
·
January 25,
2011 “Procedural
Sedation in Children”
·
February 19, 2008 “MRI
Safety”
- March 17, 2009 “More on MRI Safety”
- October 2008 “Preventing Infection in MRI”
- March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
- February 1, 2011 “MRI Safety Audit”
- October 25, 2011 “Renewed Focus on MRI Safety”
- March 13, 2012 “Medical Emergency Team Calls to Radiology”
- August 2012 “Newest
MRI Hazard: Ingested Magnets”
Some of our prior columns on the “Ticket to Ride” concept:
- April 8, 2008 “Oxygen as a Medication”
- November 18, 2008 “Ticket to Ride: Checklist, Form, or Decision Scorecard?”
Some of our previous columns on the issue of radiation risk:
· February 2, 2010 “The Hazards of Radiation”
·
November 23,
2010 “Focus
on Cumulative Radiation Exposure”
· March 2010 “More on Radiation Safety”
·
June 2011 “Progress
in Reducing Radiation from CT Scans”
·
April 2013 “Radiation
Risk of CT Scans: Debate Continues”
·
June 4, 2013 “Reducing
Unnecessary CT Scans”
·
July 2013 “More
on the CT/Cancer Debate”
References:
Abujudeh H, Kaewlai R, Shah B, Thrall J. Original Research. Characteristics of Falls in a Large Academic Radiology Department: Occurrence, Associated Factors, Outcomes, and Quality Improvement Strategies. American Journal of Roentgenology 2011; 197: 154-159
http://www.ajronline.org/doi/pdf/10.2214/AJR.10.4994
PPSA (Pennsylvania Patient Safety Authority). Falls in Radiology: Establishing a Unit-Specific Prevention Program. Pa Patient Saf Advis 2011; 8(1): 12-17
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/mar8%281%29/Pages/12.aspx
PPSA (Pennsylvania Patient Safety Authority). Radiology Falls Risk Assessment Tool. 2011
http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/falls/Documents/assessment.pdf
United States Pharmacopeia (USP) MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services”. 2006
http://www.usp.org/products/medMarx/
Darves B. Imaging hand-offs: Tips to help prevent medication errors. ACP Observer 2006; April 2006
http://www.acpinternist.org/archives/2006/04/mederrors.htm
ISMP (Institute for Safet Medication Practices). Loud wake-up call: Unlabeled containers lead to patient's death.ISMP Safe Medication Safety Alert! Acute Care Edition.December 2, 2004
http://www.ismp.org/Newsletters/acutecare/articles/20041202.asp
PPSA (Pennsylvania Patient Safety Authority). Medication Errors Occurring in the Radiology Services Department. Pa Patient Saf Advis 2009; 6(2): 46-50
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6%282%29/Pages/46.aspx
http://archsurg.ama-assn.org/cgi/content/short/145/10/978
PPSA (Pennsylvania Patient Safety Authority). Applying the Universal Protocol to Improve Patient Safety in Radiology Services. Pa Patient Saf Advis 2011; 8(2): 63-9
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/jun8%282%29/Pages/63.aspx
PPSA (Pennsylvania Patient Safety Authority). Radiology Services Patient and Procedure Identification Assessment Tool. 2011
WHO Surgical Safety Checklist: for Radiological Interventions ONLY.
Athreya S, Mikhail M, Reis Welsh S, et al. Patient Safety in Interventional Radiological Procedures: Safety Checklists and Protocols. Journal of Patient Safety 2013; 9(3): 119–121
Gibson J, Taylor DH. AHRQ Web M&M Case & Commentary “The Dangerous Detour.” June 2003
http://www.webmm.ahrq.gov/case.aspx?caseID=20
Penzias A. Implementing a Protocol to Protect Suicidal Patients in Radiology.
Journal of Radiology Nursing 2013; 32(2): 105, June 2013
http://www.radiologynursing.org/article/S1546-0843%2813%2900070-9/abstract
Penzias A, Martino J, Salazar G. The Suicidal Patient in Radiology. Suicide Risk Intervention in Imaging. (story board)
http://static.ow.ly/docs/Penzias_Suicidal_Patient_Final_1diB.pdf
Ott LK, Pinsky MR, Hoffman LA, et al. Medical emergency team calls in the radiology department: patient characteristics and outcomes. BMJ Qual Saf 2012; published online ahead of print March 2, 2012
http://qualitysafety.bmj.com/content/early/2012/03/01/bmjqs-2011-000423.short?g=w_qshc_ahead_tab
Ott LK, Hoffman LA, Hravnak M. Intrahospital Transport to the Radiology Department: Risk for Adverse Events, Nursing Surveillance, Utilization of a MET, and Practice Implications. Journal of Radiology Nursing 2011; 30(2): 49-54
http://www.radiologynursing.org/article/S1546-0843%2811%2900038-1/abstract
Ott LK, Hravnak M, Clark S, Amesur NB. Patients’ Instability, Emergency Response, and Outcomes in the Radiology Department.
Am J Crit Care November 2011; 20(6): 461-469
http://ajcc.aacnjournals.org/content/20/6/461
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3): 278-281
Shellock FG, Karacozoff AM. Detection of Implants and Other Objects Using a Ferromagnetic Detection System: Implications for Patient Screening Before MRI. American Journal of Roentgenology 2013; 201: 720-725
http://www.ajronline.org/doi/abs/10.2214/AJR.12.10332
Pindrik J, Huisman TAGM, Mahesh M, Tekes A, Ahn ES. Analysis of limited-sequence head computed tomography for children with shunted hydrocephalus: potential to reduce diagnostic radiation exposure: Laboratory investigation. Journal of Neurosurgery: Pediatrics 2013; Posted online on 20 Sep 2013.
http://thejns.org/doi/abs/10.3171/2013.8.PEDS1322?prevSearch=&searchHistoryKey=
John SD, Moore QT, Herrmann T, Don S, et al. The Image Gently Pediatric Digital Radiography Safety Checklist: Tools for Improving Pediatric Radiography. J Am Coll Radiol 2013; 10: 781-788.
http://download.journals.elsevierhealth.com/pdfs/journals/1546-1440/PIIS1546144013001488.pdf
Image Gently®. Image Gently and Digital Radiography - Quality Improvement.
http://pedrad.org/associations/5364/ig/index.cfm?page=827
Image Gently® Digital Radiography Safety Checklist
http://www.pedrad.org/associations/5364/files/Attachment%20D.CR.DR%20%20checklist.pdf
Implementation Manual. Image Gently® Digital Radiography Safety Checklist.
http://www.pedrad.org/associations/5364/files/Attachment%20C.FINAL%20Implementation%20Manual.pdf
Image Gently® Digital Radiography Safety Checklist Spreadsheet for Quality Improvement Data Collection.
http://www.pedrad.org/associations/5364/files/DigitalRadiographySafetyChecklistDatasheet.xlsx
Image Wisely®. Image Wisely Radiation Safety Case.
http://www.imagewisely.org/Case
Wachter R (ed.). AHRQ WebM&M. Perspectives in Safety. Safety in Radiology. Interview “In Conversation with…Rebecca Smith-Bindman, MD.” AHRQ WebM&M October 2013
http://www.webmm.ahrq.gov/perspective.aspx?perspectiveId=147
Pinto A. AHRQ WebM&M. Perspectives in Safety. Safety in Radiology. Perspective.
http://www.webmm.ahrq.gov/perspective.aspx?perspectiveId=148
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