Earlier this year, United States
Pharmacopeia (USP) came out with its MEDMARX® Data Report “A
Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological
Services”, an analysis of records submitted to MEDMARX specifically capturing
information on Intensive Care Units, including coronary, general, medical, and
surgical ICU's; and Radiological Services focusing on cardiac catheterization
labs, nuclear medicine, and radiology departments. The report analyzed records
only on hospital inpatients.
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.
The radiology community was prompt in condemning
the report , pointing out the relatively low overall number of
incidents, the lumping of cardiac cath labs with other radiology sites, the
observational nature of the study, and the fact that many of the errors were
attributable to problems outside the radiology department or had root causes
outside the radiology department.
Rather than reacting defensively or
indignantly, we need to recognize the real value of the USP report: it 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 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. Just as we have identified ER’s,
OR’s, and ICU’s as areas in which patients are at high risk for errors, any
other area where an inpatient might be transported for testing or treatment
should be considered a high risk area.
Below are some of the issues, conditions, and circumstances pertaining to radiology areas that may predispose patients to suffer medication (or other) errors:
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 American College of
Physicians Observer, “Imaging hand-offs: Tips to help prevent medication errors” 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.
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.
Updates: See our Patient Safety Tips of the Week February 19, 2008 “MRI Safety” and September 16, 2008 “More on Radiology as a High Risk Area” and August 11, 2009 “The Radiology Suite…Again!”.
Also, many of the patients at highest risk for transmission of nosocomial pathogens are also the likeliest to get high tech imaging studies in the radiology suite, such as CT or MRI scanning. Dr. Peter A. Rothschild has been running an excellent series on “Preventing infection in MRI: Best practices for infection control in and around MRI suites” on the radiology website AuntMinnie.com.
Rothschild PA. Preventing infection in MRI: Best practices for infection control in and around MRI suites. Auntminnie.com 2008
Part I
http://www.auntminnie.com/index.asp?sec=sup&sub=mri&pag=dis&itemid=81530
Part II
http://www.auntminnie.com/index.asp?Sec=sup&Sub=imc&Pag=dis&ItemId=81616
Part III
http://www.auntminnie.com/index.asp?Sec=sup&Sub=imc&Pag=dis&ItemId=81666
http://www.patientsafetysolutions.com
Patient
Safety Tip of the Week Archive
What’s New in the Patient Safety World Archive