Newswatch: March 2006

Report states harmful medication errors more likely in radiological services

The US Pharmacopeia (USP of Rockville, Md) has announced that medication errors occurring in radiological services produced the highest percentage of harm—seven times higher than all medication errors studied in the 2000–2004 reporting period, according to the sixth-annual MEDMARX Data Report.

"These errors signal hidden risks for patients—hidden because most people view radiological procedures as routine and might not be aware that high-risk medications are being used before, during, and after a radiological procedure," said John P. Santell, RPh, primary author of the report and director of educational program initiatives for the Center for the Advancement of Patient Safety at USP. "Based on our data, we believe this is a serious issue and it must be addressed for patient safety and quality of care."

From 2000 to 2004, 12% of the 2,032 medication errors reported in radiological services resulted in patient harm. This number is seven times the percentage of harmful errors reported in the general data set. Radiological services also were more likely to result in the need for additional care and consumption of resources.

"It's not uncommon for patients to think of radiological exams as simple X-ray procedures," Santell said. "They don't realize that very potent drugs are used in these procedures." In addition to diagnostic exams, radiological services include such procedures as draining abscesses, inserting gastric feeding tubes, inserting arterial stents, and performing angioplasties.

Breakdowns in "continuity of care" contributed to harmful medication errors. Patients often circulate quickly through radiological services without adequate communication between radiology staff and the physicians and nurses who have been providing their care. This breakdown in communication can lead to various errors, including patients receiving the wrong drug or the wrong dose of a drug, or not receiving the drug at all.

"Getting a patient moved from wherever they are in the hospital to the radiology exam, and making sure that the medications they're on going into the exam are appropriately stopped and resumed after the exam, seem to be big problems," Santell continued. "It indicates that clear responsibility isn't delegated. Should it be the floor nurse responsible for stopping and restarting the pump, or should it be the radiology staff? These questions lead to the errors that occur in the radiology department."

Besides clarifying these questions, Santell added that the patient should make sure that all of his or her allergies—not just drug allergies—have been documented. "Patients need to be aware that the physician and the other health practitioners who are performing the exam need to be aware of the patient's clinical status, which means all the allergy information. The patient, when he or she is being transported from one location to another, should make sure that his or her medical chart is going too."

The report, "A Chartbook of 2000–2004 Findings from Intensive Care Units and Radiological Services," analyzed 40,403 records collected from hospitals and healthcare institutions located across the country. MEDMARX is the largest nongovernmental database of medication errors in the United States.

For more information, visit www.usp.org/products/medMarx/ or call (800) 227-8772.