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Save a life: Take seven simple steps to avoid medication mistakes

Radiology Administrator's Compliance and Reimbursement Insider, October 1, 2006

Patients readying themselves for the latest diagnostic radiology scan should be wary of the potential harm of medication errors in the radiology department.

That’s what the U.S. Pharmacopeia (USP) suggested in its five-year report released in January, calling radiology errors seven times more harmful than errors in other areas of medical practice.

Critics called the report misleading. Leaders from no fewer than a dozen radiological societies and associations discounted the study, MEDMARX Data Report: A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services, saying that it misrepresented radiology’s diligence for quality assurance programs.

Despite the reactive fallout generated by the USP report, several potential educational and procedural initiatives were also generated. And with all of this hubbub hanging in chat room closets, there’s no better time to review the administration of medication protocols at your facility.

“We’ve had procedures and policies in place for a number of years to prevent potential medical errors in the radiology department,” says Scott Trerotola, MD, chief of interventional radiology at the University of Pennsylvania Health System in Philadelphia.

Many standards issued by multiple organizations are already in place to ensure safe patient care, the American Society for Radiologic Technologists (ASRT) said in a release earlier this year. “It is the responsibility of every medical facility and every healthcare professional to understand and follow these standards,” the release stated.

For example, close adherence to the ASRT Practice Standards for Medical Imaging and Radiation Therapy would alleviate many of the medication errors associated with radiological procedures. Among other guidelines, the ASRT practice standards clearly state that the radiologic technologist is responsible for confirming patient identity, gathering pertinent information from the patient’s medical record, and assessing factors that might contraindicate the procedure.

In its response to the USP report, the American College of Radiology said it “constantly refines practice standards designed to eliminate all foreseeable medical errors in the face of advancing technology and increasing demand for medical imaging services,” while admonishing the report’s creators for using flawed methodology.

Trerotola recommends the following seven-step process to protect your facility and patients from potential medication gaffes:

1. Conduct an initial patient assessment

2. Ask whether the patient has any allergies

3. Check existing medications

4. Go over the site markings checklist

5. Double-check patient identification

6. Create and follow a conscious sedation checklist

7. Review Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) requirements (see “Follow JCAHO guidelines to reduce medication errors” below for more information)

Keeping track of medications may seem to be a daunting task, but the solution can be as simple as marking syringes with permanent pen or purchasing pencil boxes for storage of medications. “Labeling medications is the latest thing to actually prevent medication errors,” Trerotola says. “The goal is to reduce them to their absolute minimum.”

That’s what JoAnn Belanger, RN, patient services manager at the University of North Carolina Health Care System in Chapel Hill, and her team did. They resolved one JCAHO goal—improving accuracy of drug administration—with colored pencil boxes. Each box contained a specific patient’s medication to ensure that the correct patient received the correct doses. “By labeling the medications and keeping them in the right box, we can be sure the syringe doesn’t get mixed up with any other meds,” she says.

Trerotola’s facility lays out everything needed during a procedure on a tray. “It’s not a lot of work,” Trerotola says. “There are great kits facilities can buy nowadays, [as well as] prelabeled syringes, if you can afford them. And besides, only a few drugs are used during a normal scanning procedure.”

Tip: Review internal medication error records every quarter. Try to examine at least 100 records if possible to provide a good sample. This practice will help provide an accurate understanding of what’s happening.

Communication saves lives

The USP reports indicated that medication errors frequently come from communication breakdowns. These often take place between departments as patients are transferred into the radiology department or back to their floor. Robert Henkin, MD, professor emeritus and former director of nuclear medicine at the Loyola University Medical Center in Maywood, IL, spoke with AuntMinnie.com in January about the USP report.

“The most interesting issue [the USP] raises is the difficulty in communication between nursing units and other places in the hospital,” Henkin said. The ASRT attributes these medication errors to a lack of access to patient data.

Trerotola’s hospital has medical records databases that allow his team to cross-reference patient medications and prevent potential mistakes. “Even if patients come in, and they haven’t been seen for more than a 10-year period, we have their record and we can pull it up,” he says. “The e-record is the key here.”

Although most organizations understand the importance of implementing a self-reporting system, cost, time, and fear of reprisals keep staff from being forthcoming.

Leading by example and maintaining an open dialogue between managers and staff can alleviate this problem. Resolving this issue facilitates the flow of more accurate data with organizations such as the USP. Better data means better care and healthier patients, says Trerotola.

Further, ASRT calls for additional education requirements for technologists in the following areas: