Pennsylvania Patient Safety Authority Releases March Advisory Highlighting Communication Issues That Affect Patient Safety

Main Category: MRI / PET / Ultrasound
Also Included In: Radiology / Nuclear Medicine;  Pregnancy / Obstetrics
Article Date: 28 Mar 2008 - 3:00 PDT

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Pregnant patients received x-rays (ionizing radiation) in over 90 cases reported to the Pennsylvania Patient Safety Authority in which many of the patients had indicated they were not pregnant, according to analysis published in the Authority's March 2008 Patient Safety Advisory.

Further analysis and research shows the risk however may not be as great as physicians and the public think, particularly if the pregnant patient has not had multiple diagnostic x-ray procedures. Risk also varies depending upon the radiation dose and the period of gestation of the fetus.

"While pregnant patients do not want to risk potentially harming the fetus by having unnecessary x-rays done, our research shows that risk can be minimized if the procedure must be done for medical reasons," John Clarke, MD, clinical director of the Patient Safety Authority said. "However, we also give several prevention strategies for facilities to consider implementing to reduce the risk of unnecessary x-rays to pregnant patients and we ask facilities to raise awareness of the issue."

Some of the prevention advice includes analyzing the need for the procedure, not relying only on a patient's history in determining whether or not a patient may be pregnant and raising awareness among physicians about diagnostic radiation doses and its effects to ensure the amount of risk to the exposed patient is justifiable.

"By more accurately determining the risk a patient will incur if exposed to diagnostic x-rays, healthcare providers can give more appropriate patient counseling prior to the procedure to avoid anxiety and a possible termination of a wanted pregnancy," Clarke said. "There are many factors that need to be considered and questions answered before a patient should make such a serious decision." Clarke added that some key points to promote the safe use of x-rays in pregnant women include:

• Prenatal doses from most properly performed diagnostic procedures present no significant increase of fetal death, malformation or impairment of mental development above the background incidence of these complications;
  
  
• If a diagnostic radiology examination is required to guide diagnosis and treatment, the risk to the mother of not performing the procedure is usually greater than the risk of potential harm to the fetus; and
  
  
• Ultrasound and MRI are considered safe alternatives to x-rays and can be used throughout the pregnancy.

Along with the Advisory article and prevention advice, the Authority also provides additional resources for helping facilities raise awareness that include a pocket guide discussing radiation doses of common x-ray procedures and the effects according to the pregnancy stage and a patient record to track cumulative radiation exposure. A consumer tip sheet for patients is also available to further educate them about procedures involving radiation and to help them communicate more effectively with their healthcare provider.

For more information on x-rays and the possible effects to a pregnant patient, go to the article "Diagnostic Ionizing Radiation and Pregnancy: Is There a Concern?" of the 2008 March Patient Safety Advisory here.

The Authority's quarterly 2008 March Advisory contains more articles developed from data submitted through real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights include:

• Medication Assessment to Prevent Falls: A medication assessment is often not done when assessing a patient's fall risk. As a result, patients who are at risk for falls may receive medications that increase this risk. In 2006, the Authority received reports of 33,882 drug-associated falls through PA-PSRS. While 70 percent (23,806) of the falls did not result in patient harm, 17 deaths were reported associated with the falls. Risk reduction strategies include recognizing the problem and involving pharmacy staff in developing medication assessment and reassessment strategies for patients at risk for falls. Additional fall prevention tips for patients can be found on the Authority's website at http://www.psa.state.pa.us under "Tips for Consumers."
  
  
• Treating Stroke Symptoms Quickly in the ED May Improve Outcomes: The Authority has received reports that show delays in treatment of a suspected stroke in the emergency department due to several factors including lack of staff awareness of stroke treatment protocols involving thrombolytic therapy-a method of treatment proven to reduce the effects of stroke. Given the narrow therapeutic windows for treatment of a stroke, timely evaluation and diagnosis is critical to avoid significant harm or death. Challenges are outlined in confirming a stroke diagnosis quickly and risk reduction strategies are discussed.
  
  
• Preventing the Retention of Foreign Objects: Several patients have been injured due to retained foreign objects during invasive radiology procedures performed outside the operating room setting. Interventional Radiology (IR) procedures allow physicians to use x-rays to perform certain procedures that usually involve a very small incision. However, despite the small incision, the risk of leaving behind foreign objects in the patient remains. Risk reduction strategies are discussed.
  
  
• Lab Specimens at Risk: More than 600 reports submitted to the Authority show that misusing pneumatic tubes in material transport can present a patient safety concern. Some transport issues are because of mechanical breakdowns of the pneumatic tube systems but others are a result of staff misuse and breaks in communication. Many reports relate to specimen delivery, where samples are damaged, lost or delayed in transit. Also, cases mention having to redraw or recollect the specimen. Guidelines for proper use of pneumatic tube systems are given along with other considerations for improvement.

For a copy of the 2008 March Patient Safety Advisory go to here.

The Authority also released a failure mode and effects analysis (FMEA) Advisory Supplementary Review of data collected from June 2004 and October 2006 related to the alarm response while monitoring a patient for any physical changes. This review includes analysis of 277 reports, including three that resulted in patient deaths. The reports were categorized and the FMEA completed resulting in a 29-step clinical telemetry process for alarm interventions in response to a change in a patient's physiologic condition.

For more information on the FMEA Supplementary Advisory Review or previous Patient Safety Advisories, visit the Authority's website at http://www.psa.state.pa.us.

Patient Safety Advisories