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Improving Patient Safety within a Radiology Department

Anita Bell, RT(R), RCIS, FAVIR

     *Angio-Interventional Radiology Manager, Radiology Quality Coordinator, Director of the Post-Graduate Angiography School, University of Virginia Health System, Charlottesville, Virginia.
     Address correspondence to: Anita Bell, RT(R), RCIS, FAVIR, Angio-Interventional Radiology Manager, Radiology Quality Coordinator, Director of the Post-Graduate Angiography School, University of Virginia Health System, Box 800377, Charlottesville, VA 22901. E-mail: ajb2m@virginia.edu.

Patient safety is defined as actions undertaken by individuals and organizations to protect healthcare recipients from being harmed by the effects of healthcare services.1 The term "patient safety" was first coined at the American Society of Anesthesiologists in 1984. Over the past 22 years, the focus on patient safety has become rather controversial. Preventable injury resulting from medical mistakes costs the economy $17 billion to $29 billion annually, 50% of which are healthcare-related costs, according to the report "To Err is Human: Building a Safer Health System," released by the Institute of Medicine (IOM) in 1999.2 The report also states that 44 000 to 98 000 deaths per year are related to medical errors, which are the eighth leading cause of death—more than motor vehicle accidents, breast cancer, or AIDS.

In 2004, 5 years after the eye-opening IOM report, the Henry J. Kaiser Family Foundation released a follow-up report based on a survey of 2012 US adults.3 The survey found that 48% of adults are concerned about the safety of their medical care, and 55% were dissatisfied with the quality of healthcare in the United States.3

A more recent study reveals that the problem is much more serious than the previously reported numbers. Released in April 2006, the HealthGrades report reviewed 40 million Medicare reports from 2002 to 2004, and reported 1.24 million patient-safety incidents.4 The alarming finding of the report was that 82% (250 246 of 304 702) of patient-safety-related deaths were possibly preventable.4

It has been established that the data show a problem with patient safety in the United States, and this threat extends to radiology patients. After discussing patient safety with colleagues, the following real-life examples were disclosed, which exhibit and emphasize the dire need for an increase in patient-safety precautions.

  • A radiologic technologist (RT) left a patient in a procedure room on a stretcher with the side rails up while she went to retrieve a sponge to position the patient. The patient decided that he needed to get up, so he slid himself to the end of the stretcher to get off. The entire stretcher flipped over, creating a cage over him as he lie on the floor. Luckily, the patient was not hurt.
  • An RT was performing a urokinase check and the stitches holding the sheath in place were snipped. During the snipping, the sheath was also accidentally cut. This caused a foreign body to be introduced into the vasculature and required the patient to have surgery to remove the foreign body.
  • A patient was taken to a radiology bathroom and could not find the light switch. He slipped and fell to the floor, breaking both hips.
  • When being transferred from a regular stretcher to a stretcher compatible for magnetic resonance imaging, a patient slipped between the 2 stretchers, which were not locked, and the patient fell to the floor. The fall broke the patient's hip.
  • A dialysis fistula patient was returning home after fistulagraphy in an angiography suite. The site of entry broke open and spurted blood on the windshield, causing his driver to crash.

Human Error

After 22 years of focus on patient safety and a public outcry for an improvement in patient safety, the need for actionable measures has become more obvious than ever. Unfortunately, the decisions and actions of caregivers are fraught with human error related to inattention, memory, communication breakdown, exhaustion, lack of knowledge, and environmental conditions.

Healthcare processes do not allow for human error. In healthcare, correcting human error is centered on teaching professionals to do the right thing rather than educating professionals about how to create systems to do the right thing. Errors bring about retraining, punishment, and sanctions. Human error does not mean that an adverse event is destined; however, human error during a critical human action usually results in an adverse event. To that end, many organizations concerned with patient safety define the human error that may result in an adverse event.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the forerunner of addressing human error with its Patient Safety Goals each year. Most of these goals can be applied to radiology, but even regarding those goals that do not apply directly, all radiology employees should know what they are and how their role is related. See the sidebar for additional patient-safety resources.

Safety from the Patient Perspective

There are many patient-safety issues that the radiology department has in common with other hospital departments, such as leaving patients unattended. However, there are also safety problems in radiology that are beyond the normal patient-safety issues in other areas of the hospital. These include, but are not limited to, magnetic resonance imaging safety and radiation exposure.

Radiology staff should develop a different perspective about the safety issues within their department by looking at these issues through the eyes of a patient. Staff should review the patient handbook and think about how the information shared with patients relates to radiology. For example, if the patient handbook recommends that an advocate accompany the patient, radiology staff should consider how that relates to patient visits in the radiology department. Examples of some issues to consider include whether patients need someone to accompany them to the radiology department and whether patients should have someone sit in on the consent process for interventional procedures.

Additionally, staff should review drug-dispensing units to see if similar drugs, either in name or appearance, are near each other and then separate them. Healthcare staff should take themselves through the patient experience as much as possible, from registration to riding a stretcher and wheelchair, getting on procedure tables, and looking around from each vantage point. The aspects that cannot be experienced should be closely scrutinized for potential critical human actions in which an error could be made, and then processes should be implemented to prevent error.

Patient Safety Measures

Ultimately, radiology departments must turn the focus from personnel error to system failure and it must be assumed that systems will fail. It also needs to be expected that people will make human errors regarding the systems. There will be a variance in error from person to person; therefore, processes must be designed to make it difficult for individuals to do something that was unintended. A process must be designed to identify failure points before an adverse event occurs.

Choosing from an assortment of possibilities, each hospital should tailor the failure point identification process to its situation. Failure Mode Effects Analysis (FMEA), Fault Tree Analysis, Procedure Hazard Analysis, and Worst-Case Analysis are all popular processes designed to identify failure points. JCAHO recommends FMEA because it is straight-forward, easy to learn, and has been around for decades, so it has been proven to reduce the risk of error. The link to FMEA resources can be found in the sidebar.

One question that arises when implementing changes within a department is who will do the work to make radiology a safer environment for the patient. A model that has worked successfully at the University of Virginia Health System is the development of a Radiology Patient Safety Committee. The committee is cochaired by 2 well-respected managers; it comprises staff members from each modality and work area, in addition to a physician liaison. Over the past 2 years, the committee has worked to improve communication about patient safety within the department. It created information charts for key processes, such as how different isolations should be handled and how to correct an inaccurate patient identification band or incorrect medical record demographics. The information charts also include guidelines for contrast screening matrix, JCAHO patient-safety goals, and explaining why not to use abbreviations. In addition, the committee started a campaign for patient-safety posters throughout the department, which rotate so that patients do not see the same posters all the time. These posters illustrate procedures such as how to lock stretchers, how to lower stretchers to the lowest position when parked, and leaving call bells with patients. These committee efforts have reduced patient falls by 50%. The committee also implemented the new practice of requiring outpatients to wear identification bands. This has reduced incidents of the wrong patient responding when a name is called, with no check and balance to ensure it is the correct patient. In addition, the committee reviewed and revised the Standard Operating Procedure for Receiving Patients in Radiology, reducing the number of patients left unattended. The committee's work continues and, after 2 years, it still has momentum and is positively affecting the radiology environment.

Patient safety will continue to be a high focus area for JCAHO, healthcare professionals, and the public. Because of their unique environment, radiology departments must be the front line on the patient safety issue and then share their successes with the rest of the institution.

References

1. Spath PL. Patient Safety Improvement Guidebook. Forest Grove, OR: Brown-Spath & Associates; 2000.

2. Kohn LT, Corrigan JM, and Donaldson MS, eds. To Err is Human: Building a Safer Health System. Washington, DC; National Academy Press; 2000.

3. Kaiser Family Foundation. Five years after IOM report on medical errors, nearly half of all consumers worry about the safety of their health care. Available at: http://www.kff.org/kaiserpolls/pomr111704nr.cfm. Accessed September 1, 2006.

4. HealthGrades. Third annual patient safety in American hospitals study. Available at: http://healthgrades.com/media/dms/pdf/PatientSafetyInAmerican%20HospitalStudy2006.pdf. Accessed September 1, 2006.

 

Comments/Questions

What did you think of this article?
Improving Patient Safety within a Radiology Department

 
» Comment From: diana » Posted on: 02/19/2008 23:00 PM
Patient saftey is # 1 to all rad techs. To large hospitals to small clinics. I worked as a trauma tech full-time weekends, with limited staff. Our policy was to limit our transfers on and off tables and avoid standing exams. I now work in a small climic and always use my skills for the unable patient. Good article. Should be included for CE
 
» Comment From: HANAN » Posted on: 08/17/2008 23:32 PM
Nice topics we are using the solution suggested in our hospital, as patient tag with patient name and id to avoide any error.
 
» Comment From: sylvia » Posted on: 09/29/2008 21:57 PM
Good. Patient safety is everyone responsibility. We stress the importrance of not leaving a patient while on stretcher/and during other transers - ecort provided.
 

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