Two states put radiology on patient safety radar

PA and MA both push for better efforts

Patient safety organizations in both Pennsylvania and Massachusetts issued alerts over the summer related to patient safety in radiology. Both organizations noted that they had received an increasing number of reports of reportable events that have led to them putting reviews of the issues and strategies for preventing them on their websites and for release in their regular newsletters.

The Pennsylvania Patient Safety Authority released its report in June, noting that in 2009 there were reports of more than 650 events that exposed patients to potential harm. Half were related to the wrong procedure or test, 30% related to the wrong patient, 15% to the wrong side of the patient, and 5% were wrong-site errors. Some were scheduling or order errors, while others showed inadequate procedure variation processes. Most of the errors happened in radiography (45%), followed by computed tomography (CT) scan (18%), mammography (15%), magnetic resonance imaging (MRI) (6%), and ultrasound (5%). The breakdown for the kinds of errors and the type of service was:

  • Radiography: 93 wrong patient, 104 wrong procedure, 75 wrong side, 24 wrong site
  • Computed Tomography: 36 wrong patient, 69 wrong procedure, 4 wrong side, 6 wrong site
  • Mammography:7 wrong patient, 87 wrong procedure, 4 wrong side, 0 wrong site
  • MRI:7 wrong patient, 27 wrong procedure, 5 wrong side, 0 wrong site
  • Ultrasound:13 wrong patient, 13 wrong procedure, 6 wrong side, 3 wrong site
  • Nuclear Medicine: 4 wrong patient, 8 wrong procedure, 0 wrong side, 1 wrong site
  • Interventional: 3 wrong patient, 8 wrong procedure, 0 wrong side, 0 wrong site
  • Dexa Scan: 1 wrong patient, 1 wrong procedure, 0 wrong side, 0 wrong site
  • PET:1 wrong patient, 0 wrong procedure, 0 wrong side, 0 wrong site
  • Not specified: 31 wrong patient, 14 wrong procedure, 2 wrong side, 0 wrong site

Minimizing the risk is as simple as using the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery as outlined by The Joint Commission, says the clinical director of the authority, John Clarke, MD. While developed for surgery, the protocol can be easily adapted to other areas of medicine. "These protocols, while targeted toward preventing surgery mistakes, can be used to standardize procedures in other areas of care to ensure that patients are accurately identified and procedures correctly scheduled and performed across the board, not just in the operating room," Clarke says. The authority can direct interested parties to assessment tools, sample policies, and teaching modules that can help prevent such mishaps.

For more information about the studies and data regarding radiology services, go to the Advisory article "Applying the Universal Protocol to Improve Patient Safety in Radiology Services" at the Authority's website http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/jun8%282%29/Pages/63.asp.

Massachusetts released its report in July, noting that there had been some 70 cases reported to the Quality and Patient Safety Division associated with interventional radiology procedures, most of which meet the organization's criteria for reporting Type 4 Events for unexpected patient outcomes. Of those 70 events over the last few years — the report did not specify the timeline — 19 resulted in death, 27 were bleeding complications that happened during or following a procedure, and 12 were bleeding complications following biopsy of the liver, kidney, lung, or breast (7, 2, 2, and one case respectively). There were common themes: liver disease, issues with anticoagulant/anti-platelet medications, or missing information on the patient's clotting status.

Of the bleeding complications, 15 involved disruption of a vessel or organ during the procedure, including three brain bleeds for patients on Alteplase and/or Heparin.

The Massachusetts report, available online at http://www.mass.gov/Eeohhs2, includes case studies, as well as some suggestions to prevent problems in the future. Among the suggestions:

  • Identify patients at risk for bleeding complications and ensure good communication of that information between services.
  • Clear information on patient drug protocols that include anti-coagulation, anti-platelet or NSAID use before a procedure.
  • Consistent monitoring of vital signs for 24 hours for all patients receiving thrombolytics.
  • Use smaller biopsy needles in at-risk patients.
  • Consider co-management of interventional radiology patients with anesthesia in the operating room and admitted to the surgical unit.