All Entries Tagged With: "radiation"
Diagnostic tests testing patient safety?
Diagnostic tests. They help us understand what’s wrong, and generally, they are safe. But lately, there has been concern over the amount of radiation patients receive nowadays, especially as physicians fearful of lawsuits overprescribe tests to protect themselves. There have also been a number of incidents involving CT scanning and x-ray errors that may have been harmful to patients (a trend detailed in the November issue of Patient Safety Monitor Journal).
Now we also have to worry about MRIs.
Magnetic forces, harnessed correctly, don’t harm patients, but possible adverse events when thing go wrong include projectiles, burns, fire, hearing loss, events resulting from incompatability with other medical devices, nerve stimulation, and shock.
A recent HealthLeaders Media article details an alarming rise in patient injuries, recently described at the U.S. Food and Drug Administration’s two-day session on MRI safety. Technicians need more training, guidelines for the point of care need to be better, adverse events need to be reported more, what needs to be reported needs to be better defined, and patients need better education about MRI safety, according to the session.
One thing I keep hearing, no matter the test, is that training is lacking around high-tech medical equipment, such as scanners and imaging devices. Manufacturers are pushing newer, stronger models and technicians are not trained adequately, leaving a widening patient safety gap.
Researchers win $1.2 million grant to reduce radiation exposure risk
In previous posts, we’ve blogged about the risks CT scans and X-rays have to patients. There are many concerns over the use of this technology, especially CT scans. The risk is especially high for the pediatric population, whose brains are more susceptible to the damage of radiation. They also are at the beginning of their life, making each CT scan one that should be critical, as they have to be wary of racking up too much radiation over a lifespan.
Concerns such as these have led the U.S. Institutes of Health (NIH) National Institute of Biomedical Imaging and Bioengineering to give Rensselaer researchers $1.2 million to develop software that aims help radiologists and other medical staff, as well as patients, reduce risk by providing more accurate data for CT scan decision-making.
VirtualDose will track the amount of radiation given to a patient receiving radiation. Physicians and researchers can use the software to determine how much radiation a patint receives from different CT scanning protocols or designs.
The software takes a patient’s age, sex, height, weight, and pregnancy information to create a “phantom” patient to determine radiation risk, an especially important method as children and pregnant women are most susceptible.
Despite discovery in 2007, hospital continued to follow poor X-ray practices
We wrote about State University of New York Downstate Medical Center in Brooklyn, NY in a February post. It had been made public that the hospital accidentally over radiated premature infants with full body X-rays when only chest X-rays were ord
ered. That incident was discovered internally in July, 2007, and made public a few months ago by the New York Times. The hospital did not report the discovery to state health officials.
However, The New York Times is now reporting that a March 9 state inspection found inappropriate X-rays were still being administered as recently as January, 2011. The inspection found 27 instances of improper X-ray practices on infants between late last year and early this year. Many of the instances included improper shielding, according to the Times.
Claudia Hutton, spokeswoman for the New York State Department of Health, suspects other hospitals might also be following poor practices, and told the Times the department is considering spot inspections around the state.
Radiation continues to harm–this time, the victims are preemies
A recent New York Times article has exposed yet another patient safety incident involving radiation, and this time the mistake was on premature infants at State University of New York Downstate Medical Center in Brooklyn, NY.
The incident, which was discovered in July, 2007, is one of several that has prompted the Times to run its “Radiation Boom” series, which explores the increasing use of medical radiation though new and old technologies, including over radiation of cancer and stroke patients, much of which is caused by misuse of equipment.
Over radiation at Downstate Medical Center occurred from too-frequent full body X-rays of premature babies, CT scanners’ radiation levels being set too high, and poorly positioned babies, making it hard to interpret images.
Radiation regulations are sparse. According to the Times, it’s up to states to decide what, if any, standards radiologists and other similar technicians need to meet. In some states, hair dressers might have tougher standards, and many states do not require continuing education for radiology technicians, though equipment is often updated and becoming increasingly more complex.
Are you confident in your hospitals radiation policies? Is it a concern? Post below.
Tracking radiation doses in patients
A recent Associated Press report tells us that Americans receive the most medical radiation in the world, and that our radiation exposure through medical tests has grown sixfold in a couple of decades.
Often, neither physician nor patient knows how much radiation he or she has been exposed to through tests. (The AP cited a 2007 Columbia University study that predicted that in a few decades, 2% of all cancer will be the result of medical radiation exposure.) The article also points out that physicians don’t order doses of radiations, they simply order for the scans to be done, and each scan can vary in amount of exposure given.
KevinMD commented on his blog on the topic, and suggests perhaps electronic medical records may eventually help track a patient’s radiation exposure long-term.
Is this something your hospital is concerned with? How difficult would it be to track radiation?
Professional radiation organization calls for new safety protocols
The American Society for Radiation Oncology (ASTRO) has issued a six point plan for improving quality and patient safety, as well as reducing medical errors, reports the New York Times. This comes after the paper published two articles recently about the potential for radiation therapy-related errors due to the complicated technology necessary for administering the treatment, and the role of human error. You can read my original blog post about this article here.
Although radiation errors are rare, the damage that results when they do occur can be extremely serious and sometimes deadly. ASTRO has called for the creation of a database to report errors in conjunction with linear accelerators and CT scanners. This would be a large step for the field because there doesn’t currently exist a system for tracking radiation therapy-related errors. Also, the group will work to ensure that medical technology manufacturers create radiation therapy machines that can easily transfer patient data to one another.
To read more about ASTRO’s call for more safety measures in the New York Times, click here.
New York Times article exposes radiation therapy errors
In a horrifying and emotional account, the New York Times explored the topic of radiation therapy errors in a recent article, one which I would recommend when you have 10 or 15 minutes to sit down and read. Although radiation therapy errors are severely underreported, the New York Times reviewed cases from New York State, which is one of the most progressive states when it comes to reporting this type of error. Between 2001 and 2008, 621 radiotherapy mistakes were reported or recorded, many of which were minor. However, those that were not proved to be deadly and painful for the recipients along the way.
At the heart of the two major errors described in the story is technology failure, combined with human failure. Radiation therapy is delivered to cancer patients via complex technological equipment which in turn must be worked by well-trained medical physicists. If both components (the technology and the staff) are not doing their jobs as they should be, an error can occur. The harrowing accounts of two patients involve repeated error–equipment not functioning correctly and staff not catching the error for many days in a row.
Although the story is about radiation therapy, and not surgery, I couldn’t help but think about the Universal Protocol (UP) throughout reading it. If the surgical team is supposed to do a last minute time out to ensure that the correct patient is about to recieve the correct procedure to the correct area of the body, why are there not similar protocols in place for something like radiation therapy? Perhaps because these errors are less reported, there is less known about how to prevent them? Perhaps there are and this story did not bring them to light? Perhaps there are but (as with the UP sometimes) technologists ignore some steps?
Anyway, be sure to check out the article yourself. As a patient safety professional you may be interested to see it highlight many aspects of an error that can be found in much more minor errors (communication failures, human factors, software malfunction), perhaps something you experience during your more often than extreme radiation errors.
Medical imaging putting patients at risk?
The Boston Globe has an interesting article today about the dangers of medical imaging. A study in the August New England Journal of Medicine shows that 70% of adults have undergone some sort of medical scan that exposed them to radiation in the past three years. While the majority of those radiation doses were relatively low, 20% received moderate doses. What’s more, 2% of adults received high or very high doses. This means they were exposed to more radiation than workers in the healthcare and nuclear industries are allowed to be exposed to annually, putting them at a higher risk for developing cancer.
This is mainly because of the number of medical scans has increased dramatically in the U.S. in the past two decades. Of course, the information contained in a medical scan often warrants its occurrence. Images have gotten clearer and patients who know that imaging is an option often request they have one. However, the researchers in this study are asking how many scans is too many.
Brigham and Women’s Hospital in Boston is adding information to its electronic medical record system that will allow physicians to see how many medical scans a patient has undergone within the Partners system (which owns the hospital) to allow physicians to make more informed decisions about scheduling further scans. This is a fairly advanced option, one that many health systems in the U.S. do not use. However, the cumulative effects of radiation may soon warrant this type of monitoring system on a larger scale.
You can read the full article here. Do any of your patients ever express fear about the amount of radiation they are receiving from medical scans? Do you as a healthcare provider ever have reservations about ordering a scan for that reason?
