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Tip of the Week Archive Jul-Sep 2022

Tips, Tools, Techniques, and Resources You Can Use in Your Patient Safety and Quality Improvement Initiatives

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Patient Safety Tip of the Week

July 12, 2022

Radiologists Racked by Interruptions

Just as interruptions and distractions can be problematic for any clinician, they can also impact radiologists (see our Patient Safety Tip of the Week for July 1, 2014 “Interruptions and Radiologists” and our What's New in the Patient Safety World columns for November 2014 “More Radiologist Interruptions” and May 2018 “Cost of Interrupting a Radiologist”). If a radiologist gets interrupted while interpreting an imaging study, he/she may forget a point they were intending to make in a report. Or they may have to go back to square one and begin review of the imaging study as a brand new one. If interrupted while dictating a report, they may have to go back to the beginning to be sure they have included all the necessary information.

Unfortunately, “radiology rounds” have largely become a thing of the past. In the “old days” our team of attendings, residents and students would finish rounding on patients and then head down to the radiology suite. There we would meet with a radiologist and review the images of our patients that were all hanging on the radiology “boards?”. So, it was a time the radiologist set aside from interpreting images and dictating reports. Today, with images on PACS systems, clinicians are likely to view images on their patients remotely. When they have questions, they contact the radiologist by phone (or other method). This results in the radiologist having more frequent interruptions and incursions on their workflow.

In our July 1, 2014 Patient Safety Tip of the Week “Interruptions and Radiologists” we took a look at the impact of interruptions and distractions on the workflow of radiologists. A study (Yu 2014) found that during a typical 8PM to 8AM overnight shift there was an average of 72 telephone calls, with a median call duration 57 seconds, and the average time spent on the phone was 108 minutes. The median interval from the start of one telephone call to the start of the next ranged from 3 to 10 minutes, depending on the time of day. There was also a correlation between volume of phone calls and the volume of CT scans being done (volume of other imaging studies was not measured as part of this study). That study did not include any measure of image interpretation accuracy or disparities between interpretations by the on-call radiologist and any subsequent interpretations.

In our What's New in the Patient Safety World column for November 2014 “More Radiologist Interruptions” we noted another study found a relationship between telephone calls to radiology residents on-call and discrepancies on reports (Balint 2014). There was a statistically significant increase in the average number of phone calls in the 1 hour preceding the generation of a discrepant preliminary report. The authors suggest that one additional phone call during the hour preceding the generation of a discrepant preliminary report resulted in a 12% increased likelihood of a resident error.

Recently, Shah and colleagues (Shah 2022) studied the workflow and impact of interruptions on pediatric radiologists at a large academic free-standing pediatric tertiary care facility with level 1 trauma. They found that total interruption time nearly equaled the total time interpreting studies for radiologists!

A business process improvement team was consulted to observe the activity of academic pediatric radiologists in the general, neuroradiology, and body reading rooms during daytime, evening, weekday, and weekend shifts. Activities were broken down into interpretation time (time spent reviewing and dictating studies), active interruptions (disruptions in interpretation initiated by the radiologist), and passive interruptions (disruptions in reading studies not initiated by the radiologist).

Three reading rooms were studied. The main reading room was responsible for interpreting the bulk of the radiographs and all inpatient ultrasound exams. It is situated close to the emergency department and is considered the “central hub” of the department. The neuroradiology reading room was responsible for all head, neck, and spine cross sectional imaging including CT and MRI scans. The body reading room was responsible for all cross-sectional non-neuro exams including musculoskeletal, cardiac, abdomen, and pelvic exams. Each reading area typically has 2 radiologists and up to 3 trainees, which may include medical students, residents, and fellows. Each reading area has its own workflow and resources. The main reading room had a dedicated reading room assistant who answers and triages incoming phone calls before notifying the radiologist.

Overall, radiologists spent 53% of their time interpreting studies, 18% on passive interruptions, and 29% on active interruptions, though the numbers varied by reading room type. Interruptions also varied by time of day with peaks during mid-morning and midafternoon times, corresponding with increased hospital-wide consultation of radiology. A majority of the interruptions were related to patient care.

Approximately 50% of non-interpretive time involved in-person conversations or consults (51% with colleagues, 17% with trainees, 16% with clinicians, and 14% with technologists). Other examples of non-interpretive activities included: calling a clinician, talking to a technologist, teaching a trainee, speaking with a colleague, signing paper orders, protocoling studies, responding to emails, administrative work, and technology issues. Phone calls represented 16% of non-interpretive time, of which 67% were incoming calls. Administrative work, including e-mail, comprised 13% of all non-interpretive time.

The longest time period recorded without an interruption was 20 minutes. Perhaps most importantly, 85% of the time an interruption came within 3 minutes of beginning an interpretation. 90% of interruptions lasted less than 3 minutes or less and 70% lasted 1 minute or less.

Interruptions clearly decreased efficiency and increased report interpretation times for all modalities studied. Interruptions not only cost the radiologist whatever time it took to address the interruption, but also cost additional total time to finalize the report dictation. Duplication of work occurred, as radiologists often needed to start again from the beginning when interpreting imaging studies.

There, of course, are “bad” interruptions and “good” interruptions. An interruption during which a radiologist conveys important information to a clinician is a “good” interruption. But, are there better ways to convey that information without interrupting the workflow of the radiologist? Shah and colleagues have some useful recommendations. They redesigned the central radiology reading room, combining the neuroradiology and body radiology reading rooms with sound barriers and strategic placement of a reading room assistant at the entrance to triage phone calls and direct visitors to the appropriate location. The reading room assistant hours were expanded to 24/7 and training was improved to assure consistency. Standardized phone call intake forms helped radiologists filter out non-urgent requests that could wait until an interpretative task was completed.

Asynchronous communication can help reduce radiologist interruptions and improve their workflow. Rather than having to respond to every individual phone call, some questions may be posed by text message or email and the corresponding responses made in between times when the radiologist is interpreting an imaging study or dictating a report. Fewer interruptions also mean the radiology reports can be posted on the PACS system or in the electronic medical record more promptly, further reducing the need for some interruptions. (Keep in mind the dangers of texting noted in our several columns listed below. However, most of those cautions apply to the issue of texting orders.)

Shah and colleagues implemented text-based communication through the EMR and phone-based application for more efficient communication with other departments and clinicians. A new PACS with worklist orchestrator and department-wide text-based communication is planned for the future.

They also addressed interruptions from radiology technologists. Imaging protocols were improved and standardized to minimize phone calls from technologists while assuring high quality image acquisition. Technologist training was also increased to allow for more independence and fewer instances of interrupting the radiologist.

And they modified trainee rotation schedules to assure that no more than one trainee would be with a radiologist at a time.

We suspect that an audit of interruptions for radiologists in most hospitals would reveal similar findings. The study by Shah and colleagues should give you some ideas to jump start a program of minimizing those interruptions and improving workflow and productivity of your radiologists.

Prior Patient Safety Tips of the Week dealing with interruptions and distractions:

August 25, 2009 “Interruptions, Distractions, Inattention…Oops!”
November 3, 2009 “Medication Safety: Frontline to the Rescue Again!”
December 15, 2009 “The Weekend Effect”
May 4, 2010 “More on the Impact of Interruptions”
October 12, 2010 “Slowing Down in the OR”
March 8, 2011 “Yes, Physicians Get Interrupted Too!”
July 31, 2012 “Surgical Case Duration and Miscommunications”
August 28, 2012 “New Care Model Copes with Interruptions Better”
November 27, 2012 “Dealing with Distractions”
April 16, 2013 “Distracted While Texting”
May 21, 2013 “Perioperative Distractions”
July 1, 2014 “Interruptions and Radiologists”
November 2014 “More Radiologist Interruptions”
March 17, 2015 “Distractions in the OR”
July 21, 2015 “Avoiding Distractions in the OR”
August 30, 2016 “Can You Really Limit Interruptions?”
November 8, 2016 “Managing Distractions and Interruptions”
March 7, 2017 “Nested Interruptions”
April 11, 2017 “Interruptions: The Ones We Forget About”
February 13, 2018 “Interruptions in the ED”
May 2018 “Cost of Interrupting a Radiologist”
December 2019 “Hospitalist Shifts Matter, Too”

January 28, 2020 “Dang Those Cell Phones!”
September 2020 “AORN on Distractions and Interruptions”
February 23, 2021 “Cellphones and the OR”
November 2021 “New Risk Factor for Patient Safety Events: Motor Vehicle Accidents”
January 11, 2022 “Documenting Distractions in the OR”

See our other Patient Safety Tip of the Week columns dealing with texting:

February 9, 2016 “It was just a matter of time…”
May 24, 2016 “Texting Orders – Is It Really Safe?”
January 2017 “Joint Commission Thinks Twice About Texting Orders”
June 27, 2017 “Texting – We Told You So!”
January 30, 2018 “Texting Errors Revealed”

January 28, 2020 “Dang Those Cell Phones!”
February 23, 2021 “Cellphones and the OR”

Some of our prior columns on patient safety issues in the radiology suite:

October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
February 19, 2008 “MRI Safety”
September 16, 2008 “More on Radiology as a High Risk Area”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”
October 2008 “Preventing Infection in MRI”

March 17, 2009 “More on MRI Safety”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

August 11, 2009 “The Radiology Suite…Again!”
January 2010 “Falls in the Radiology Suite”
August 2010 “Sedation Costs for Pediatric MRI”
January 25, 2011 “Procedural Sedation in Children”

February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
February 25, 2014 “Joint Commission Revised Diagnostic Imaging Requirements”
July 2014 “New MRI Risks: for Staff!”
July 1, 2014 “Interruptions and Radiologists”
November 2014 “More Radiologist Interruptions”
October 21, 2014 “The Fire Department and Your Hospital”
June 23, 2015 “Again! Mistaking Antiseptic Solution for Radiographic Contrast”
August 25, 2015 “Checklist for Intrahospital Transport”
March 22, 2016 “Radiology Communication Errors May Surprise You”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, ,2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 14, 2017 “Tracking C. diff to a CT Scanner”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
April 2018 “Radiologists Get Fatigued, Too”
May 2018 “Cost of Interrupting a Radiologist”
November 2018 “OMG! Not My iPhone!”
December 11, 2018 “Another NMBA Accident”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 12, 2019 “Patient Photographs Again Help Radiologists”
November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
January 7, 2020 “Even More Concerns About MRI Safety”
July 14, 2020 “A Thesis on Intrahospital Transports”
August 25, 2020 “The Off-Hours Effect in Radiology”

October 2020 “New Warnings on Implants and MRI”
January 2021 “New MRI Risk: Face Masks”
May 25, 2021 “Yes, Radiologists Have Handoffs, Too”

June 1, 2021 “Stronger Magnets, More MRI Safety Concerns”
November 2021 “Yet Another Risk During MRI”
January 2022 “MRI Safety Issues”
February 2022 “Managing Incidental Findings”
June 2022 “Where Are You Barcoding?”

References:

Yu J-P, Kansagra AP, Morgan J. The Radiologist's Workflow Environment: Evaluation of Disruptors and Potential Implications. JACR 2014; published online April 26, 2014

http://www.jacr.org/article/S1546-1440%2813%2900850-8/pdf

Balint BJ, Steenburg SD, Lin H, et al. Do Telephone Call Interruptions Have an Impact on Radiology Resident Diagnostic Accuracy? Academic Radiology 2014; published online September 30, 2014

http://www.academicradiology.org/article/S1076-6332%2814%2900307-9/abstract

Shah SH, Atweh LA, Thompson CA, et al. Workflow interruptions and effect on study interpretation efficiency. Current Problems in Diagnostic Radiology 2022; Published online 27 June 2022

https://www.sciencedirect.com/science/article/abs/pii/S0363018822000871?via%3Dihub

Print “Radiologists Racked by Interruptions”

July 19, 2022

Sucked Out of the Plane at 17,000 Feet

Our regular readers know we like to use aviation analogies to make points about safety in healthcare (see list of prior columns below). We are giving a course on “Why Accidents Happen” and one of our examples is well worth telling here. The following comes from the book “Inviting Disaster” by James R. Chiles and 2 videos “Blow Out”, a short version and a long version.

On June 10, 1990 British Airways Flight 111 left Birmingham, England on a flight to Malaga, Spain with 87 passengers and crew aboard. As the aircraft climbed out, the captain and copilot unbuckled their chest straps but left their lap belts loosely fastened. Then, at 17,000 feet, the windscreen pulled loose and flew up and over the nose, snapped off a radio antenna and fell free. A force of 5500 pounds pulled the captain out of his seatbelt and launched him headfirst into the window frame. His legs and feet were lodged in the console but he was now mostly outside the plane in zero degree temperature and windspeed 396 miles per hour. Hypothermia was very likely to kill him even if he did not fall out completely.

The cockpit and cabin filled with fog (the decompression takes water vapor out of the air) and wind whistled through the cockpit at 350+ mph. The copilot could not hear anything else and could not communicate with air traffic control. The captain’s legs and feet, still lodged in the console, were actually causing the plane to increase speed. A downed cabin door also contributed to lack of access to controls. The copilot knew he must descend to lower altitude, so passengers and crew do not suffer from lack of oxygen. He must descend blindly over Heathrow airspace, one of the busiest in the world, thus risking a mid-air crash.

A flight steward enters the cockpit and grabs hold of the captain’s legs. Another steward enters and moves the fallen cabin door, freeing up the controls. The copilot descends to a safe level and makes contact with air traffic control (ATC). He asks for emergency landing at Gatwick Airport, which he is familiar with. ATC suggests Southampton airport instead. The copilot is concerned because he thinks he needs at least a 2200 meter runway (because of full fuel load that cannot be dumped) and Southampton has only 1800 meter runway. ATC still says to go to Southampton anyway and it deploys emergency vehicles there.

Flight stewards took turns holding the captain’s legs, while the copilot reduced speed and altitude. Crew was certain the captain was already dead and, at one point, had to decide whether to let the captain go. The decision to keep holding on to him was based as much on risk factors to the plane (fear his body would damage wings or jet engine) as well as the remote chance they could save him.

The copilot managed a safe emergency landing on the short runway at Southampton 18 minutes later. There the captain was whisked off in an ambulance. In the ambulance his eyes began to open. He’s still miraculously alive!!! He suffered frostbite, cuts and bruises, and several broken bones but survived. Five months later he returned to pilot again.

That was the drama. You can watch both a short version and a long version of these events online.

But the lessons came after the successful landing.

The investigation began immediately. There was no evidence of structural damage to the fuselage and no glass shards or fragments were found, so a bird strike or collision with other object was excluded. The investigator reviewed logs and saw that recent maintenance had been done. So the investigation moved back to Birmingham, England.

At 3:00 AM that morning the plane had rolled into the maintenance facility at Birmingham, England for a windscreen replacement that needed to be finished by 6:30 AM so the aircraft could get a wash before starting the day’s flight to Malaga, Spain. Windscreens must be strong enough to resist tons of force from cabin pressure when the airplane is at high altitudes. A hard-working maintenance manager decided to take on the awkward job of replacing the sixty-pound slab of layered glass and plastic himself. He began the job at 3:00 AM. He had replaced aircraft windscreens six times before, but he still read through that part of the maintenance manual quickly. Then he gathered his tools, positioned a scaffold, and climbed up to unscrew ninety bolts from the rim of the windscreen. He had a new windscreen ready and he had the pile of original bolts, eighty-four of which he knew to be of size 7D and six of them a little longer. But some of the bolt heads had globs of dried paint on them and others had been scarred from the removal process. He refused to take the easy course of using as many of the old bolts as possible, replacing only the damaged ones. He wanted to replace them all.

He went to the storeroom with a sample of the bolts he needed. The 7D bolt bin had only a few on hand, far less than he needed. The man in charge of the storeroom told him he should be using 8D bolts for a windscreen replacement, anyway. He disregarded that comment, figuring that since 7D bolts had worked before, they would work again. (The proper bolt actually was the 8D.)

There was a standby parts depot located two miles away, so he drove there. Most of the bins weren’t marked, none were supervised, and the lighting in this part of the building was bad. He kept digging until he found a bin of bolts that, when he held one up in the gloom alongside his old 7D, looked to be the same. In fact, the ones he found were neither 7D’s nor the proper 8D’s. The eighty-four unmarked bolts he loaded up and took back with him to the hangar were size 8C. They were one-fortieth of an inch narrower in diameter than the 7D’s he wanted. When he was finished, of all ninety bolts, only six long bolts of the correct size actually held the windscreen fast.

So, what were the contributing factors in this case that we also often see in healthcare incidents? The lead investigator in this incident said that there were “something like 13” contributing factors to this accident and that correction or avoidance of any one of them would have prevented the accident. Sound familiar? In healthcare incidents we typically see such a cascade of events and contributing factors, avoidance of any one of which would have prevented the adverse outcome.

Fatigue may well have played a role. The maintenance work took place in the middle of the night, beginning at 3:00 AM and not finishing until near the end of the maintenance manager’s shift. Time pressures clearly played a role. This work had to be done so the flight could get washed at 6:30 AM prior to its early departure time. So, all the work had to be compressed into the period between 3:00 AM and 6:00 AM. In the airline industry (and most industries), “time is money”.

Work overload likely contributed as well. There were so many ongoing maintenance jobs that the manager had to do this job on his own. In addition, there were likely distractions, since the manager was in charge of all work being done and was concerned how all the other jobs were going, even while doing his own project.

Workarounds were a major contributor. People often take pride in their workarounds and may be considered “resourceful” Some workarounds are indeed “resourceful” and useful, but most are not and can be dangerous. In this case, the workaround was that the manager did not look at the parts catalog. He told the investigators, apparently with a sense of pride, that finding the correct bolts is “easier to do visually”. In fact, bypassing the parts catalog apparently had become the norm in this maintenance facility. We refer to that as “normalization of deviance”.

Assumptions played a big role. The manager matched up bolts to the ones he had removed. The old ones had been in place for 4 years, apparently without incident. He assumed that, if the old ones worked, the new ones will work.

And 2 of the common cognitive biases we so often see in healthcare incidents came into play here: confirmation bias and ignoring disconfirming evidence. The bolts looked like they were the same size as the ones he had removed. “I got 7D bolts out, I put 7D bolts back in”. There were at least 2 bits of disconfirming evidence. He ignored stockroom worker’s warning that those were not the correct bolts and he also ignored the fact that the bolts went in without the usual resistance you’d expect when putting them in.

Overconfidence (or hubris) also played a role. When asked why he ignored the storeroom clerk’s statement that those were the wrong bolts, the manager said “Well, I’m an engineer…”.

There were also environmental factors. The hangar was full and the plane was pushed up against a wall, making it difficult for the manager to work on the windscreen. The lighting in the auxiliary parts storeroom was poor, making identification of the bolts difficult.

And there was also a critical design flaw. The bolts on this aircraft windscreen went in from the outside. On newer models, the bolts go on the inside. If the bolts loosened at high altitude, the higher cabin pressure inside the plane would push the windscreen against the fuselage rather than having the windscreen blow out as it would on the old design.

And there was probably a latent factor: the old bolts were actually the wrong size!!! It’s incredible this accident had not occurred earlier. Perhaps those 6 long bolts had been originally located just strategically enough to prevent a blowout?

When we look at an incident, there is typically a “sharp” end. The root causes and other contributing factors at the “blunt” end add up and leave a human with “the smoking gun”. The lead investigator in this incident said “This investigation uncovered pressures in the hangar that caused an otherwise proficient engineer to make potentially lethal mistakes while being certain he was doing the right thing”.

Lastly, this incident was technically a “near miss” since the ultimate outcome for the pilot and the 87 passengers and crew was not physically detrimental. As in many healthcare incidents that are “near misses”, a little bit of luck is important. On the bad luck side, the pilot happened to be sitting on the side of the defective windscreen and had loosened his shoulder harness. On the good luck side, all were lucky the plane did not hit any other planes as they descended blindly through crowded airspace and that the runway was just long enough for a fully fueled plane to be able to stop. And the hypothermia the captain undoubtedly experienced as he lay outside the aircraft may well have protected his brain from the lack of oxygen he also undoubtedly experienced.

We know this is not a healthcare incident. But we hope you can all see the common root causes, latent factors, cognitive biases, and other contributing factors seen in this case are often present in our serious healthcare incidents. If you have time, the long version is quite dramatic and worth watching. It’s just over 51 minutes but you’ll be impressed by it.

This case is also a reminder that accidents often follow maintenance activities. Many high profile industrial disasters (Three Mile Island, Chernobyl, Bhopal, Piper Alpha) and many airline disasters occurred during maintenance procedures. Our August 7, 2007 Patient Safety Tip of the Week “Role of Maintenance in Incidents” discussed the book “Managing Maintenance Error” by James Reason and Alan Hobbs. Maintenance may be a factor in some healthcare incidents as well. Our March 5, 2007 Patient Safety Tip of the Week “Disabled Alarms” described a near-miss in which tape placed over an oxygen blender alarm on a ventilator during maintenance resulted in lack of a warning when the ventilator became disconnected from it oxygen source while in use on a patient.

See some of our previous columns that use aviation analogies for healthcare:

May 15, 2007 “Communication, Hearback and Other Lessons from Aviation”

August 7, 2007 “Role of Maintenance in Incidents”

August 28, 2007 “Lessons Learned from Transportation Accidents”

October 2, 2007 “Taking Off From the Wrong Runway”

May 19, 2009 “Learning from Tragedies”

May 26, 2009 “Learning from Tragedies. Part II”

January 2010 “Crew Resource Management Training Produces Sustained Results”

May 18, 2010 “Real Time Random Safety Audits”

April 5, 2011 “More Aviation Principles”

April 26, 2011 “Sleeping Air Traffic Controllers: What About Healthcare?”

May 8, 2012 “Importance of Non-Technical Skills in Healthcare”

March 5, 2013 “Underutilized Safety Tools: The Observational Audit”

April 16, 2013 “Distracted While Texting”

May 2013 “BBC Horizon 2013: How to Avoid Mistakes in Surgery”

August 20, 2013 “Lessons from Canadian Analysis of Medical Air Transport Cases”

December 17, 2013 “The Second Victim”

January 7, 2014 “Lessons from the Asiana Flight 214 Crash”

January 5, 2016 “Lessons from AirAsia Flight QZ8501 Crash”

October 23, 2018 “Lessons From Yet Another Aviation Incident”

References:

Chiles JR.. Inviting Disaster. HarperCollins. Kindle Edition. 2008

https://www.amazon.com/Inviting-Disaster-Lessons-Edge-Technology-ebook/dp/B0018ND83Y/ref=sr_1_1?crid=36WAG892VXFWF&keywords=inviting+disaster&qid=1657120741&s=books&sprefix=inviting+disaster%2Cstripbooks%2C102&sr=1-1

Blowout (short version). British Airways Flight 5390; October 22, 2016

https://www.youtube.com/watch?v=pOcm6E10anI

Blow Out (full episode). The Captain That Got Stuck Outside Of The Plane! Mayday: Air Disaster; September 10, 2021

https://www.youtube.com/watch?v=7xfaDr0nhoQ

Reason J, Hobbs A. Managing Maintenance Error. Aldershot, England: Ashgate Publishing Limited, 2003

Print “Sucked Out of the Plane at 17,000 Feet”

July 26, 2022

More Risks in the Radiology Suite

You’ve seen our multiple columns describing the radiology suite as being high-risk for patient safety events. In our October 22, 2013 Patient Safety Tip of the Week “How Safe Is Your Radiology Suite” and the other columns listed below we’ve discussed the multitude of safety issues seen in radiology suites that have little to do with radiology per se. That’s because sick patients with multiple medical problems and vulnerabilities are being taken to the radiology suite and staying there, sometimes for prolonged periods. The events include things like falls, medication errors, patient mixups, IV connection errors, running out of oxygen, conscious sedation incidents, suicides, and others.

But sometimes factors related to the imaging procedure may also contribute to patient safety events. Sanchez et al. (Sanchez 2022) recently discussed cases of 2 patients given IV sedation to facilitate MRI scans. In one, a 43-year-old woman with acute neurological symptoms and signs was given lorazepam 2 mg intravenously (IV) as premedication to reduce agitation after a first attempt at doing the MRI was unsuccessful. The MRI was again unsuccessful, despite anxiolysis. After returning to the medical unit, flumazenil 0.2 mg was given due to somnolence, with subsequent improvement in mental status.

In the second case, a 71-year-old man with a possible epidural abscess following a bout of sepsis was sent for an MRI scan. He was unable to tolerate the scan due to back pain, so hydromorphone 0.5 mg IV was administered. Because of continued restlessness, additional doses of lorazepam 1 mg IV and hydromorphone 0.4 mg IV were ordered. After the patient received a 3rd dose of lorazepam 1mg IV, he became obtunded, hypotensive, and developed respiratory depression with oxygen saturation around 60%. The rapid response team was called, and naloxone and flumazenil were administered. The patient was placed on bilevel positive airway pressure (BiPAP) and given a fluid bolus before being transported to the intensive care unit (ICU), where he was emergently intubated. The patient remained intubated for several days due to severe acute respiratory distress syndrome (ARDS), which was attributed to aspiration while in the MRI machine.

Sanchez et al. provide a nice discussion of the risks of minimal-to-moderate sedation for imaging procedures, especially in high-risk patients, when multiple medication doses are required, and when monitoring is limited or inadequate (e.g., inside an MRI machine). They highlight the need for risk assessment prior to administering such drugs and consideration of patient-specific risk factors for respiratory depression. They stress such risk factors for oversedation as obesity, hepatic, renal, and lung disease; substance use disorder, and obstructive sleep apnea. They recommend looking for higher American Society of Anesthesia (ASA) physical status classification and checking a STOP-BANG score to help identify patients who might have unrecognized obstructive sleep apnea. In addition, they note that lower BMI values are associated with higher plasma concentrations of fentanyl or midazolam, two commonly used medications for diagnostic imaging sedation. They also suggest assessing the patient for potential aspiration risk and considering NPO (nothing by mouth) orders prior to diagnostic imaging procedures with sedation.

They caution against “dose-stacking” of medications (administering medications multiple times and/or from various routes before each dose reaches its peak therapeutic effect).

Monitoring is very important. Because of variability and risk for oversedation, patients must be assessed before and after each dose or medication administration. They note that consistent sedation assessments are important throughout the duration of action of the medication(s) administered. They emphasize “Continuous electronic monitoring is indicated for moderate levels of sedation or higher and should be considered for high-risk patients receiving opioids and/or benzodiazepines.”

They also stress an important point that is often overlooked – sedation might be avoided all together in many patients. They discuss non-pharmacologic techniques that can be used to minimize anxiety, agitation, and claustrophobia prior to such imaging studies. These include positioning issues, use of movie goggles, mirrors, 2-way communications, call buttons, and even fragrance administration.

Nice, practical discussion of a problem we continue to see all too often in patients undergoing imaging studies.

Some of our prior columns on patient safety issues in the radiology suite:

October 16, 2007 “Radiology as a Site at High-Risk for Medication Errors”
February 19, 2008 “MRI Safety”
September 16, 2008 “More on Radiology as a High Risk Area”
October 7, 2008 “Lessons from Falls....from Rehab Medicine”
October 2008 “Preventing Infection in MRI”

March 17, 2009 “More on MRI Safety”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”

August 11, 2009 “The Radiology Suite…Again!”
January 2010 “Falls in the Radiology Suite”
August 2010 “Sedation Costs for Pediatric MRI”
January 25, 2011 “Procedural Sedation in Children”

February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
March 13, 2012 “Medical Emergency Team Calls to Radiology”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
February 25, 2014 “Joint Commission Revised Diagnostic Imaging Requirements”
July 2014 “New MRI Risks: for Staff!”
July 1, 2014 “Interruptions and Radiologists”
November 2014 “More Radiologist Interruptions”
October 21, 2014 “The Fire Department and Your Hospital”
June 23, 2015 “Again! Mistaking Antiseptic Solution for Radiographic Contrast”
August 25, 2015 “Checklist for Intrahospital Transport”
March 22, 2016 “Radiology Communication Errors May Surprise You”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, ,2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
November 14, 2017 “Tracking C. diff to a CT Scanner”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
April 2018 “Radiologists Get Fatigued, Too”
May 2018 “Cost of Interrupting a Radiologist”
November 2018 “OMG! Not My iPhone!”
December 11, 2018 “Another NMBA Accident”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 12, 2019 “Patient Photographs Again Help Radiologists”
November 26, 2019 “Pennsylvania Law on Notifying Patients of Test Results”
January 7, 2020 “Even More Concerns About MRI Safety”
July 14, 2020 “A Thesis on Intrahospital Transports”
August 25, 2020 “The Off-Hours Effect in Radiology”

October 2020 “New Warnings on Implants and MRI”
January 2021 “New MRI Risk: Face Masks”
May 25, 2021 “Yes, Radiologists Have Handoffs, Too”

June 1, 2021 “Stronger Magnets, More MRI Safety Concerns”
November 2021 “Yet Another Risk During MRI”
January 2022 “MRI Safety Issues”
February 2022 “Managing Incidental Findings”
June 2022 “Where Are You Barcoding?”
July 12, 2022 “Radiologists Racked by Interruptions”

Some of our prior columns on patient safety issues related to MRI:

February 19, 2008 “MRI Safety”

March 17, 2009 “More on MRI Safety”
October 2008 “Preventing Infection in MRI”
March 2009 “Risk of Burns during MRI Scans from Transdermal Drug Patches”
January 25, 2011 “Procedural Sedation in Children”
February 1, 2011 “MRI Safety Audit”
October 25, 2011 “Renewed Focus on MRI Safety”
August 2012 “Newest MRI Hazard: Ingested Magnets”
October 22, 2013 “How Safe Is Your Radiology Suite?”
October 21, 2014 “The Fire Department and Your Hospital”
August 25, 2015 “Checklist for Intrahospital Transport”
August 2016 “Guideline Update for Pediatric Sedation”
October 2016 “MRI Safety: There’s an App for That!”
January 17, 2017 “Pediatric MRI Safety”
August 8, 2017 “Sedation for Pediatric MRI Rising”
March 2018 “MRI Death a Reminder of Dangers”
March 2018 “Cardiac Devices Safe During MRI But Spinners!?”
November 2018 “OMG! Not My iPhone!”
April 2, 2019 “Unexpected Events During MRI”
September 2019 “New MRI Hazard: Magnetic Eyelashes”
October 15, 2019 “Lots More on MRI Safety”
November 5, 2019 “A Near-Fatal MRI Incident”
November 2019 “ECRI Institute’s Top 10 Health Technology Hazards for 2020”
January 7, 2020 “Even More Concerns About MRI Safety”
March 2020 “Airway Emergencies in the MRI Suite”
October 2020 “New Warnings on Implants and MRI”
January 2021 “New MRI Risk: Face Masks”
June 1, 2021 “Stronger Magnets, More MRI Safety Concerns”
November 2021 “Yet Another Risk During MRI”
January 2022 “MRI Safety Issues”

References:

Sanchez L, Porras H, Lammers C. Medication Safety Events Related to Diagnostic Imaging. AHRQ PSNet Web M&M July 8, 2022

https://psnet.ahrq.gov/web-mm/medication-safety-events-related-diagnostic-imaging

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