Radiation safety: It's complicated
Preventing adverse outcomes to keep patients safe
After reading this article, you will be able to:
- Understand the reason for Sentinel Event Alert 47
- Identify contributing factors to the issue of radiation overexposure
- Recognize ways to prevent repeat radiation exposure
X-rays, CT scans, and MRIs are used widely and often in healthcare facilities across the United States. Chances are, most people have received at least one x-ray at some point in their lives, whether for a broken bone or a routine dental exam, and in many cases, diagnostic imaging is necessary to correctly diagnose an issue in order to save lives and prevent further injuries or infections.
But radiation is toxic, and even though x-rays are helpful diagnostic tools, the long-term effects of radiation may be harmful. Experts are still debating the long-term risks of radiation exposure, but according to The Joint Commission's Sentinel Event Alert 47, x-rays are considered a carcinogen by the World Health Organization's International Agency for Research on Cancer, the Agency for Toxic Substances and Disease Registry of the Centers for Disease Control and Prevention, and the National Institute of Environmental Health Sciences.
Joint Commission Sentinel Event Alert 47 urges healthcare organizations to seek new ways to reduce exposure to repeated doses of radiation from diagnostic procedures, and says that over the past two decades, the U.S. population's total exposure to ionizing radiation has nearly doubled. According to one study, the incidence of cancer related to CT radiation is 0.02%-0.04%.
A multifaceted issue
There are a multitude of factors at play in radiation overexposure, and unfortunately there is no one single problem with respect to diagnostic imaging. It's an incredibly complex problem that involves staffing, accreditation organizations, administration decisions, and the equipment used to deliver radiation, as well as the manufacturers and the physicists who perform routine quality assurance/quality control on the machines.
In addition, many technologists who operate radiology equipment are not certified, and many states do not require continuing education, even though the machines are constantly being updated due to advances in technology as well as hardware and software from different machine manufacturers being combined.
Who's to blame?
Tobias Gilk, M. Arch., radiation design specialist for RAD-Planning, an architectural design and planning consultant firm specializing in radiology, nuclear medicine, and radiation therapy facilities in Kansas City, MO, says that mistakes are triggered by any one of the moving parts associated with radiation exposure. Fingers can be pointed in a number of directions depending on the situation, says Gilk, who also works for Med Novice, a company that manufactures and sells safety equipment for the MRI environment; has been involved in providing radiology training information for The Joint Commission; and served on the American College of Radiology's MRI safety committee.
"There was a case in northern California from a couple of years ago that was pretty directly attributable to the training of the technologist, where the tech administered a single CT exam to a pediatric patient in excess of 70 times because the patient was a 2-year-old child who was having difficulty holding still for the exam. There are pictures of this young boy taken after the exam, and he has what appears to be a sunburn in a very clearly defined line that begins right at the cheekbone and extends down to his collarbone, and that sunburn is a result of radiation burns from the repeated CT exam. That's an example of a staff training issue," says Gilk.
There are also recent examples of multifaceted issues peppered across the country involving an available software upgrade that added a CT perfusion function (a type of scan that allows perfusion to an organ to be measured by CT) to existing CT scanners that were originally sold to hospitals without such a function, Gilk says. Software that manages the new protocol often is not fully integrated into the new system, creating a separate pop-up window that gives the recommended dosage information associated with the perfusion exam in a place where the technician may not be accustomed to seeing it. Technicians then click through and dismiss the information, overlooking the window alerting them that they are giving excessive doses.
Gilk says that because there are so many moving parts, it is difficult to say whether the training or the technology is to blame, and in some ways, it's an artificial differentiation anyway. He says that although training on these machines is absolutely essential, it would be a misnomer to put all of the blame on the technologist who is hands-on with the patient and the device. "We are seeing situations where enterprises are reducing staffing levels or reducing employee experience to try to manage personnel costs. If that leaves more accidents because of a ‘hurry up and scan more patients with fewer people' mentality or ‘do more with less,' then that accident should justly fall at the feet of the administration.
Most of the time, these accidents are an interplay between equipment, personnel, and management, and it's the kind of situation where if we simply broke one link in the sequence of events, we would have a good shot at preventing the adverse outcome," he says.
Owning up to the challenge
While there are certainly examples of errant technicians, poor software integration, or breakdowns in quality assurance on the part of the manufacturer, Gilk says the challenge really boils down to culture and accountability. Because these systems are so complex, the healthcare workplace must adopt a professional culture that accepts shared responsibility.
What is really needed, he says, is for every party involved to not only consider their discrete job duties or responsibilities, but to assume a shared responsibility for the safety of the patient, even if that means overlapping duties with the other players in the enterprise. "It's through these gaps in responsibility and narrow definitions of roles that these kinds of accidents are allowed to occur. The silo mentality is what ultimately injures and runs the risk of killing patients needlessly," says Gilk.
Taking the first steps
Gilk says risk assessment and risk management are the first steps hospitals should take to ensure mistakes don't happen at their facility. "Before they rush out and decide they're going to take these steps, I think it's prudent to say, ‘Well, where are we in terms of providing safe and effective care?' " he says.
Gilk reminds organizations that for Joint Commission-accredited facilities, measuring risk is a part of the accreditation process. Although it's not an issue that has been enforced with any consistency in regard to radiology and radiation therapy, Gilk says it is clearly spelled out in The Joint Commission's Environment of Care standards.
"Organizations should turn directly to EC.02.01.01," he says, "which references Sentinel Event Alerts, and go through the 21 performance objectives identified for Sentinel Event Alert 47, and measure the facility against each and every one of those. Once they have their report card, then they can take a look at what is going to be the most effective way to manage these risks and ultimately make care for the patients safer and more effective."
No simple solutions
Gilk says the issue is much more complex than just providing four hours of continuing education for technicians, hiring a medical physicist to come to the facility and check everything, or switching to an accreditation organization that provides a higher level of scrutiny in this area.
Organizations that take these steps are not necessarily making poor choices. In fact, Gilk thinks organizations that look at this problem holistically are going to choosemany of these solutions; however, what he hopes to emphasize is that this problem cannot be fixed with simple band-aid solutions.
"What I don't want is for facilities to think that the solution is ‘fill in the blank,' " he says. "I don't want facilities to think that all we need to do is that one thing and the problem is solved, because in all honesty the solution is two or three or seven things done in concert."