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Publication Type: Sentinel Event Alert
Single or Multiple Incident: Multiple
Date: 8/24/2011 12:00:00 AM
This alert addresses the risks of diagnostic imaging and fluoroscopy with regard to repeated doses, insufficient radiation and overall risks from diagnostic imaging. The higher the dose of radiation delivered at any one time, the greater the risk for long-term damage. If a patient receives repeated doses, harm can also occur as the cumulative effect of those multiple doses over time. Conversely, using insufficient radiation may increase the risk of misdiagnosis, delayed treatment, or, if the initial test is inadequate, repeat testing with the attendant exposure to even more radiation. The risks associated with the use of ionizing radiation in diagnostic imaging include cancer, burns and other injuries. The alert identifies patients most pront to harm. The purpose of the alert is to inform and support healthcare organization to reduce risks due to avoidable ionizing radiation by raising awareness among staff and patients of the increased risks associated with cumulative radiation doses and by providing the right test and the right dose through effective processes, safe technology and a culture of safety. Recommendations addressing these strategies are provided.


Environment / Equipment
  1. Perform an organization-wide audit/survey of imaging equipment that have the potential of emitting high amounts of radiation. Implement a system for centralized quality and safety performance monitoring of this inventoried equipment under the supervision of a medical physicist, radiation safety officer, or your organization’s multidisciplinary group with radiation expertise or both.
  2. Have a medical physicist test all imaging equipment initially and at least annually for CT, NM, PET, and fluoroscopic units to assure proper installation and calibration, and to review scanning protocols and doses.
  3. Ensure that recommended quality control, testing (including daily functional tests) and preventive maintenance activities are performed in accordance with manufacturer’s guidelines. The health care organization, in consultation with the medical physicist, should identify these activities, their frequencies, and who will perform them.
Rules / Policies / Procedures
  1. In order to reduce the exposure of the patient to ionizing radiation, use other imaging techniques, such as ultrasound or MRI, whenever these tests will produce the required diagnostic information at a similar quality level.
  2. Adhere to ALARA guidelines as required by the Nuclear Regulatory Commission. The ALARA acronym stands for “as low as reasonably achievable” – making sure doses are as low as possible while achieving the purposes of the study. Adhere to the Image Wisely®, Image Gently® and Step Lightly® guidelines when providing imaging radiation to children and adults.
  3. Provide physicians and technologists with reference doses based on anatomy, purpose of the study, and patient size. Establish appropriate dose ranges for high-volume and high-dose diagnostic imaging studies.
  4. Radiologists should assure that the proper dosing protocol is in use for the patient being treated.
  5. Institute a process for the review of all radiation dosing protocols either annually or every two years to ensure that protocols adhere to the latest evidence.
  6. Investigate patterns of radiation exposures that fall outside of identified thresholds for appropriate doses. Identify opportunities for process improvement. Track radiation doses from exams repeated due to insufficient image quality or lack of availability of previous studies to identify the causes. Address and resolve these problems through education and other measures.
  7. Record the dosage or exposure as part of the study’s summary report of findings.
  8. Create and implement policies and procedures delineating those responsible for approving changes to password-protected diagnostic imaging protocols and for monitoring new developments in diagnostic imaging and fluoroscopy. Provide for oversight of these policies and procedures and related activities, including control of the password, by a multidisciplinary group with expertise in radiation (such as a radiation safety committee), including a medical physicist.
  9. Develop and implement policies and procedures that delineate physical protective risk reduction measures to be taken by staff delivering radiation to patients, including appropriate lead shielding for both patients and employees and radiation-protection training for all technologists.
  10. Designate an individual to serve as radiation safety officer. Ensure that the role has the needed leadership support to intervene when unsafe practices related to the provision of ionizing radiation are noted. The radiation safety officer should participate on the organization’s patient safety committee.
  11. Use the following Joint Commission standards to support the use of safe and effective diagnostic radiation and fluoroscopic imaging: LD.03.01.01, LD.03.04.01, LD.03.05.01, LD.03.06.01, LD.04.01.05. The concepts in these standards promote a safety culture, which is necessary for the safe use of diagnostic radiation. A safety culture is expressed in the beliefs, attitudes and values of an organization’s employees regarding the pursuit of safety. It is present in the organization’s structures, practices, controls, and policies, which are used to achieve greater safety.
  12. The Joint Commission endorses the creation of a national registry to track radiation doses as the start of a process to identify optimal and reference doses.
  13. The Joint Commission encourages manufacturers to incorporate dosage safeguards into equipment and to capture dose information in the patient’s electronic medical record and national dose registry.
  14. The Joint Commission supports stricter regulations designed to eliminate avoidable radiation exposures and monitor the appropriateness of self-referred imaging studies (referral of a patient to a facility in which the referring physician has a financial interest).
Training
  1. Create and implement processes that enable radiologists to provide guidance to and dialogue with referring physicians regarding the appropriate use of diagnostic imaging using the American College of Radiology’s Appropriateness Criteria.
  2. Ensure all practitioners (including physicians) and technologists who either prescribe, supervise, or operate equipment used to perform patient exams or procedures that involve radiation exposures receive dosing education and are trained on the specific make and model of equipment being used. Institute a process for annual education, review and competency testing.

Radiation risks of diagnostic imaging and fluoroscopy