We’ve talked about the radiology suite as being a site at high risk for adverse events and medical errors (see our Patient Safety Tips of the Week for October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”, February 19, 2008 “ and September 16, 2008 “More on Radiology as a High Risk Area”).
Our October 16, 2007 Patient Safety Tip of the Week “Radiology as a Site at High-Risk for Medication Errors” discussed multiple types of medication errors that can occur when patients are in the radiology suite. That article was based primarily on the United States Pharmacopeia’s 2004 MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services”.
Importantly, we’ve noted that most of the events have nothing to do with radiology, per se, but rather that you have sick patients with complex problems being brought to an area prone to handoff fumbles. We pointed out at least 14 reasons why such errors are common in radiology areas.
Last month’s Pennsylvania Patient Safety Authority “Patient Safety Advisory” added new data to previous reports on medication errors occurring in the radiology suite. The PPSA found almost 1000 medication events in radiology areas over a 5-year period in Pennsylvania’s incident reporting system. Though contrast agents and radiopharmaceuticals were the leading drugs involved, the vast majority of involved agents had nothing to do with radiology. Rather, they were drugs used in the medical management of the patient elsewhere. And those that frequently led to patient harm were high alert drugs like insulin and heparin.
Especially problematic in the radiology suite are drug infusions that must be interrupted for the radiology procedure to be performed. These infusions are often omitted, given at the wrong rates, or there may be failure to give a loading bolus after interrupted infusions. Connecting tubing to the wrong catheter site (catheter misconnection) has also been seen.
The use of moderate sedation (the politically correct name for what we used to call conscious sedation) is not unusual in the radiology suite and is fraught with all the same dangers we see with moderate sedation elsewhere. In fact, it may be even more risky since lack of ready access to the MAR (medication administration record) may obscure the fact the patients have already received before they came to the radiology suite sedating agents, narcotics, or other medications that may be additive with the drugs being used for moderate sedation.
One type of error we had not previously encountered that was noted often in the PPSA report is that due to confusion of various Technetium formulations. There are apparently over 60 different products containing various technetium formulations used in imaging.
The PPSA advisory also notes that ready access to the patient’s full medical chart is often lacking in the radiology suite. There may be lab data that would influence the decision to use contrast which is not reviewed prior to contrast use.
Furthermore, during some procedures verbal orders are given, adding an additional opportunity for communication errors such as giving a medication but not recording it.
When we are asked about good topics for a FMEA (failure mode and effects analysis), medication administration in the radiology suite is always near the top of our list. That is one recommendation the PPSA also makes in its report. They also recommend proactively discussing plans for managing infusion therapy prior to transport to radiology.
Our old friend, the checklist, is the perfect fit for radiology procedures. Yet we see very few radiology departments using them. They should be used to verify the correct identity of the patient and the correct procedure, check critical lab results before administering contrast, managing IV medications, managing oxygen, labeling all vials and basins, etc.
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 another 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. And, indeed, another recent Pennsylvania Patient Safety Authority “Patient Safety Advisory” discussed development of a standardized handoff communication tool for intrahospital transports. It has an excellent discussion on the development of questions you’ll want to use in your own transport communication tool.
Again, the bottom line is that you must anticipate the dangers in patients being transported to the radiology suite and prepare for them ahead of time.
United States Pharmacopeia. MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services”. 2007
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Medication Errors Occurring in the Radiologic Services Department.
Pa Patient Saf Advis 2009; Jun;6(2): 46-50.
Pennsylvania Patient Safety Authority. Patient Safety Advisory. Safe Intrahospital Transport of the non-ICU Patient Using Standardized Handoff Communication.
Pa Patient Saf Advis 2009; Mar;6(1): 16-9.