Patient Safety Tip of the Week
September 16, 2008
More on Radiology as a High Risk Area
Several of our most popular articles in the past have dealt with patient safety in the radiology suite. Our October 16, 2007 Patient Safety Tip of the Week “Radiology as a Site at High-Risk for Medication Errors” focused on the fact that many incidents and adverse events occurring in the radiology suite have little to do with radiology per se. And on February 19, 2008 we looked at MRI Safety.
But our interest was piqued again when we came across an article on, of all things, the economic justification of a dedicated portable CT scanner at the Cleveland Clinic (Masaryk 2008). Note that the online link has the authors and title transposed with those of another article. The article demonstrates the cost effectiveness of having a dedicated portable CT scanner to scan ICU patients. It projected a net economic benefit of $264,658 in the first year and total benefit of $2.6 million over 5 years (the savings coming from decreased transport costs plus freeing up the scanner to do more outpatient scans).
But the real beauty of the Masaryk article is the reference list, which includes several articles from the 1980’s and 1990’s on issues related to transport of ICU patients to radiology. A paper by Smith et al (Smith 1990) noted 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. Another study (Indeck 1988) showed 68% of all transports from trauma ICU’s for diagnostic studies experienced serious physiologic changes of 5 minutes duration. However, a subsequent study (Hurst 1992) that used a matched control group in the ICU that was not transported showed significant physiologic changes in 68% of transported patients but also in 60% of control ICU patients. A program at the University of Missouri (Stearley 1998) showed that use of a specifically trained ICU transport team had an overall complication rate of only 15.5%, most of the complications being minor.
USP’s 2007 MEDMARX® Data Report “A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services” showed that though the overall number of medication errors in radiology areas was small, 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.
Our July 31, 2007 Tip of the Week on “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. ISMP (ISMP 2005) has also noted cases of neuromuscular blocking agents being inadvertently given in radiology areas.
In fact, doing a search on the ISMP website for events related to radiology results in many “hits”. A patient suffered a fatal arrest when given 20 mg. of labetalol by rapid IV push as the patient was being rapidly transported to radiology (ISMP 2003). And the types of misadventures reflect many of those seen elsewhere in the hospital, including connecting blood pressure monitoring tubing to IV ports (ISMP 2003b), fatal gas line mixups (ISMP 2004), administration of chloral hydrate syrup by the IV route when a nurse in radiology confused the Roman numeral IV in the Drug Enforcement Agency (DEA) class four controlled substance symbol (C-IV) as “intravenous.”(ISMP 2008), incorrect doses of epinephrine (ISMP 2002), and the fatal injection of antiseptic skin prep solution that was in an unlabeled basin and was confused with contrast solution (ISMP 2004b).
An AHRQ Web M&M case (Foley 2005) described a case where a non-radiology nurse administered oral contrast for a radiology procedure intravenously.
In our October 16, 2007 Patient Safety Tip of the Week “Radiology as a Site at High-Risk for Medication Errors” we noted at least 14 factors that make adverse events more likely in the radiology suite. Undoubtedly there are many more contributing factors and conditions.
So it is quite clear that the radiology suite serves as a microcosm of all the adverse patient safety events that occur throughout a hospital. A good patient safety program in radiology would include both continuous surveillance for error-prone practices and a proactive approach using FMEA. One possible approach is that taken at Partners Healthcare System (Kahlon 2006). They focus on several specific areas of interest and utilize both RCA’s and FMEA. We’d recommend expanding that radiology patient safety team to include representatives from other services (eg. medicine, surgery, nursing, anesthesiology, respiratory therapy, pharmacy, etc.). We also strongly recommend that the radiology suite be one area frequently visited during patient safety walkrounds. Consideration for special designated transport teams, such as that described in the Stearley article, might be reasonable for ICU patients though we’d like to see some more research on that topic.
Update: See also our August 11, 2009 Patient Safety Tip of the Week “The Radiology Suite…Again!”.
References:
Masaryk T, Kolonick R, Painter T, Weinreb DB. The Economic and Clinical Benefits of Portable Head/Neck CT Imaging in the Intensive Care Unit. Radiology Management. Mar-Apr 2008
http://www.ahra.com/RM/NEWRMShow.asp?ID=778
Smith I, Fleming S, Cernaianu A. Mishaps during transport from the intensive care unit. Critical Care Medicine. 1990; 18(3):278-281
Indeck M, Peterson S, Smith J, et al. Risk, cost, and benefit of transporting ICU patients for special studies. J Trauma. 1988; 28(7): 1020–1025
Hurst JM, Davis K Jr, Johnson DJ, et al. Cost and complications during in-hospital transport of critically ill patients: a prospective cohort study. J Trauma. 1992; 33(4): 582–5 http://www.jtrauma.com/pt/re/jtrauma/abstract.00005373-199210000-00014.htm;jsessionid=LPqHnZbyD1J0RnJq4PX3nvr9wJgK1v5CjvLRzjRzLvkRfWsmJqzG!-2013963969!181195629!8091!-1?index=11&database=ppvovft&results=1&count=10&searchid=3&nav=search
Stearley HE. Patients' outcomes: intrahospital transportation and monitoring of critically ill patients by a specially trained ICU nursing staff. American Journal of Critical Care. 1998; 7(4):282-7
ISMP. Medication Safety Alert. Paralyzed by mistakes. Preventing errors with neuromuscular blocking agents. Medication Safety Alert Acute Care Edition. September 22, 2005
http://www.ismp.org/Newsletters/acutecare/articles/20050922.asp
ISMP. Medication Safety Alert. How fast is too fast for IV push medications? Medication Safety Alert Acute Care Edition. May 15, 2003
http://www.ismp.org/Newsletters/acutecare/articles/20030515.asp
ISMP. Medication Safety Alert. Blood pressure monitor tubing may connect to IV ports. ISMP Medication Safety Alert Acute Care Edition. June 12, 2003 http://www.ismp.org/Newsletters/acutecare/articles/20030612.asp?ptr=y
ISMP. Medication Safety Alert. Fatal gas line mix-up: How to avoid making this "gastly" mistake. ISMP Medication Safety Alert Acute Care Edition. December 16, 2004
http://www.ismp.org/Newsletters/acutecare/articles/20041216_2.asp
ISMP. Medication Safety Alert Acute Care Edition. Safety Brief: “C-IV” mistaken as “IV.” Medication Safety Alert Acute Care Edition. July 17, 2008
http://www.ismp.org/Newsletters/acutecare/archives/July08.asp#17
ISMP. Medication Safety Alert Acute Care Edition. It doesn't pay to play the percentages. Medication Safety Alert Acute Care Edition. October 16, 2002
http://www.ismp.org/Newsletters/acutecare/articles/20021016.asp
ISMP. Medication Safety Alert. Loud wake-up call: Unlabeled containers lead to patient's death. ISMP Medication Safety Alert Acute Care Edition. December 2, 2004
http://www.ismp.org/Newsletters/acutecare/articles/20041202.asp
Foley ME. AHRQ Web M&M Case & Commentary. Infused, not Ingested. November 2005.
http://www.webmm.ahrq.gov/case.aspx?caseID=108&searchStr=oral+contrast
Kahlon, Prerna S.Patient safety: a collaborative,
blame-free, team approach.
SourceRadiology Management. 2006; 28(1):47-50
http://www.ahra.com/RM/NEWRMShow.asp?ID=600&type=basic
http://www.patientsafetysolutions.com
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