1. © 2011 Pennsylvania Patient Safety Authority Applying the Universal Protocol to Improve Patient Safety in Radiology Services Theresa V. Arnold, D.P.M. Senior Patient Safety Analyst Applying the Universal Protocol to Improve Patient Safety in Radiology Services Theresa V. Arnold, D.P.M. Senior Patient Safety Analyst

2. © 2011 Pennsylvania Patient Safety Authority “Wrong” Events: Not Only in the OR Multiple factors –Similarity of site, procedure, and patient names –Breakdowns in communications and teamwork –Patient and procedure factors –Failed safety checks 2 Wrong patient Wrong procedure Wrong side Wrong site

3. © 2011 Pennsylvania Patient Safety Authority Archives of Surgery Study- 2010 All wrong-patient events involved errors in communication “Non-surgical disciplines equally contribute to patient injuries related to wrong-site procedures” Expand protocols to prevent wrong events to include nonsurgical specialties 3

4. © 2011 Pennsylvania Patient Safety Authority Wrong Events by Radiology Study 4

5. © 2011 Pennsylvania Patient Safety Authority PA-Patient Safety Reporting System Data Events reported in 2009 identified three main sources of error: –Ordering and scheduling errors –Patient misidentification –Inaccurate procedure verification Side or site Need for study 5

6. © 2011 Pennsylvania Patient Safety Authority Main Sources of Patient Harm Unnecessary radiation −Higher the dose of radiation at any one time, the greater the risk for long-term damage Delay in diagnosis and treatment Incorrect treatment 6

7. © 2011 Pennsylvania Patient Safety Authority Causes of Wrong-Site Procedures Acting on the basis of misinformation −Wrong information on the schedule, order, or given by the patient Having a misperception of the patient’s situation −Right/left confusion −Patient symptomatology 7

8. © 2011 Pennsylvania Patient Safety Authority 1. Ordering and Scheduling Inaccuracy Inaccurate order entry or scheduling from: –Hospital patient care areas –Physician offices –Radiology registration or clerical personnel –Technologist selecting wrong study option 8

9. © 2011 Pennsylvania Patient Safety Authority 1. Ordering and Scheduling Inaccuracies A patient arrived at the radiology front desk for a scheduled appointment. The patient handed the medical office assistant her request and the assistant logged her as arrived for a two-view chest x-ray. While preparing to scan the request, the assistant noticed that the exam was for a chest CT scan and not a chest x-ray. The patient had already been taken into the x-ray room and the images acquired. 9

10. © 2011 Pennsylvania Patient Safety Authority 2. Patient Misidentification Patient identity not verified using two identifiers –Patient or a representative was not included in the identification process “What is your name and date of birth?” 10 Patients misidentified by using –Room number –Procedure or study

11. © 2011 Pennsylvania Patient Safety Authority 2. Patient Misidentification Transport called to bring patient A to radiology. Transport brought patient B with patient A’s medical record. Technologist verified the name on medical record and asked patient if her name was patient A. Patient responded “yes.” The exam was performed. Nurse then called and informed technologist that the wrong patient was transported to the [radiology] department. 11

12. © 2011 Pennsylvania Patient Safety Authority 3. Procedure Verification Lack of policies or procedures to verify intended studies –Clinical correlation not performed to support need for study 12

13. © 2011 Pennsylvania Patient Safety Authority 3. Procedure Verification Inadequate screening before imaging study –MRI, pregnancy, and renal function –Current use of a contraindicated medication (e.g., metformin) Order or prescription misinterpretation –Illegibility of chart notes, orders, or prescriptions (e.g., improper contrast administration) Procedure duplication 13

14. © 2011 Pennsylvania Patient Safety Authority A patient arrived for an upper external arterial ultrasound exam. The technologist identified the patient and began asking the patient about her leg symptoms. The patient described symptoms of the lower extremities, which seemed appropriate for the exam. The technologist was interrupted by phone calls and, distracted, performed a lower extremity exam without first verifying the physician’s order. The error was discovered after the end of the exam and the patient was rescheduled. 14 3. Procedure Verification

15. © 2011 Pennsylvania Patient Safety Authority 4. Side or Site Misidentification Site misidentification occurred when: –Technologists were distracted –Technologists relied on the direction and symptomatology of the patient order was not available order or physician’s prescription referenced an alternate side or site –Student technologists were inadequately supervised. 15

16. © 2011 Pennsylvania Patient Safety Authority The patient’s mother stated the child fell on his left side and needed a left clavicle x-ray. The child was upset and crying during the procedure. The physician’s office had ordered [the x-ray] for the right clavicle. The patient returned for right [clavicle] x-ray. 16 4. Side/site Misidentification

17. © 2011 Pennsylvania Patient Safety Authority Physician Office Protocols Lacked protocols to verify clinical information before scheduling a study or procedure: −Physician did not confirm orders before staff scheduled procedure –Two forms of patient identification were not used –Incorrect radiologic study or site of study was ordered by the physician without verifying accuracy Required additional scanning of the correct site or performance of another study 17

18. © 2011 Pennsylvania Patient Safety Authority Physician Office A patient arrived for a scheduled MRI of the cervical spine. The physician’s order was for the thoracic spine. MRI of thoracic spine was completed. The physician’s office notified MRI when they received results of incorrect test. Test was scheduled correctly, but physician’s order was incorrect. 18

19. © 2011 Pennsylvania Patient Safety Authority Physician Office Mammograms were commonly ordered or scheduled inaccurately −60% improperly ordered −73% screening instead of diagnostic −17% diagnostic instead of screening −10% unspecified error −40% improperly scheduled 19

20. © 2011 Pennsylvania Patient Safety Authority Near Miss or “Good Catch” Events An order was placed by the intensive care unit for a CT [computed tomography ] scan of the thoracic spine. When the patient was brought down [to radiology], the order was written for a cervical spine. The patient was put on the table. The physician’s office was called because the order did not specify CT. The doctor stated he wanted plain x-rays of the cervical spine. The patient was taken to the x-ray [unit] for his films. The nursing unit was notified that they placed the wrong order. 20

21. © 2011 Pennsylvania Patient Safety Authority Strategies to Improve Patient Safety Obtain leadership support Standardize policies and procedures to reduce variability Apply the principles of the Universal Protocol –Verification and reconciliation –Site referencing –Time-out 21

22. © 2011 Pennsylvania Patient Safety Authority Applying the Universal Protocol Patient consented to left L4/5 epidural and L4/5 facet injection. Surgeon marked left side preoperatively. In the OR, the patient was placed prone and fluoro was used to position the patient and a time-out was done. All members agreed with L4/5 level. X-ray tech preprogrammed machine the day before and inadvertently typed the level as L5/S1. This showed up on the fluoro viewing screen during the procedure. After the procedure, surgeon noted that the level injected did not match OR paperwork and notified the patient. 22

23. © 2011 Pennsylvania Patient Safety Authority Strategies to Improve Patient Safety Everyone is ACCOUNTABLE –Review all available documents o Verify that the requisition and the medical record order or physician’s prescription are consistent –Verify orders that are unclear, illegible or inconsistent with patient expectations o Consult radiologist –Implement “read back” to confirm verbal orders 23

24. © 2011 Pennsylvania Patient Safety Authority Strategies to Improve Patient Safety Ensure two unique patient identifiers –Involve two independent technologists –Use patient-specific identifiers –Promote patient awareness of identification protocols –Assess staff competency with compliance 24

25. © 2011 Pennsylvania Patient Safety Authority Visit the Authority’s Website 25

26. © 2011 Pennsylvania Patient Safety Authority Available Resources 26

27. © 2011 Pennsylvania Patient Safety Authority QuestionsQuestions 27