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 “More on Radiology as a High Risk Area” and August 11, 2009 “ ”.and September 16, 2008 “
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