Patient Safety Tip of the Week

October 16, 2007

Radiology as a Site at High Risk for Medication Errors

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:

· 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 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

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Patient Safety Tip of the Week Archive

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Patient Safety Tip of the Week

October 16, 2007

Radiology as a Site at High Risk for Medication 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.

· 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 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.

· 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.