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Publication Type: Patient Safety Advisory
Single or Multiple Incident: Multiple
Date: 6/1/2017 12:00:00 AM
This alert discusses the patient safety incidents that can occur with the use of radiological contrast media. Although the administration of radiologic contrast media is generally safe, it is not without risks. Most adverse events are mild and do not result in permanent patient harm. 4065 event reports from the Pennsylvania Patient Safety Reporting System gathered over a 2-year period, from January 2014 through December 2015 addressed IV, oral, and enteral routes of contrast administration. The majority of the event reports were Incidents (i.e., near miss event or events that reached the patient but did not result in harm or require additional interventions): 99.2%. The remaining 0.8% events were Serious Events, in which an event reached the patient and resulted in harm—including severe extravasations, nephrotoxicity, and cardiac events—and required additional intervention. Almost two-thirds of the event reports (63.4%) were related to IV contrast infiltrations or extravasations. Another 22.1% were related to allergic reactions. The alert provides more information on the type of adverse reactions experienced, prevention and treatment of same.

Additional Details

Device:
power injectors
Medication/Gas/Fluid:
low osmolar, nonionic, monomer, and nonionic iso-osmolar dimer contrast media, iodinated contrast media - Omnipaque®, Visipaque™ corticosteroids silicone sulfur papaverine, metformin beta blockers
Medication/IV List:
radiocontrast agents, IV neuromuscular blocking agents oral hypoglycemics

Rules / Policies / Procedures
  1. Visually inspect the product for discoloration and particulate matter prior to administration.
Training
  1. Education on the importance of timing the administration of metformin relative to the administration of radiologic contrast media may help reduce likelihood of a delay in obtaining the contrast study and the risk of nephrology complications.

Radiology Contrast Concerns: Reports of Extravasation and Allergic Reactions