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One of the first lessons I learned when I was an actor was this: You have to be willing to fail. You must take risks, and if you make a mistake ? well, that’s how you grow. Nobody likes making mistakes. As an editor, I make them. There are the typical typos and, less often, the incorrect fact. I’m not happy when it happens, and I try to learn from my mistakes.
But mistakes have far greater repercussions for those in the medical field. Actors and editors have the luxury of “growing from their experience” (and/or retracting a statement). But physicians, nurses, and techs have a whole lot more at stake. Their errors can literally mean the difference between life and death.
According to the National Academy of Sciences’ Institute of Medicine, an estimated 44,000 to 98,000 Americans die each year from preventable medical errors. It isn’t just at hospitals, it’s also in physicians’ offices, clinics, and outpatient centers. The errors happen at retail pharmacies as well as in nursing homes and in other institutional settings.
But I sometimes wonder if medical imaging professionals—so often involved in diagnosing rather than treating patients, and often at arm’s length from the patient—focus enough on the issue of medical errors. If you are not thinking about it, that may be your greatest mistake of all.
Errors happen in medical imaging—across modalities and across a diverse patient population. Consider, for example, mammography. I recently received an e-mail from someone who signed it as “Concerned Tech.” She wrote, “Most facilities are interested in numbers; how many mammograms they can do per hour. Most places are short-staffed and want to schedule every 10 to 15 minutes and take as many add-ons as possible. They expect one single mammotech to do a large volume of work ? .”
“Concerned Tech” was worried about “burnout.” Burnout leads to human error. It’s easy to imagine an overworked tech performing sloppy exams. That, in turn, can lead to missed problems—missed diagnoses—for the radiologist.
Safety is a concern in the MRI suite as well. In February 2008, The Joint Commission issued a Sentinel Event Alert based on the hundreds of MRI accidents over the last decade. A 10-year study showed 389 incidents ranging from burns to magnet incidents on patients with pacemakers. Most alarming of all—MRI accidents resulted in nine deaths.
Then there is the all-important matter of contrast media injection. Accidents happen.
A health care professional may “improperly seat a catheter in the vein, accidentally administering intravenously infused contrast media into surrounding tissue during an MR procedure. Or a provider could confuse one medication with another while manually filling syringes.” (See our story by Associate Editor Elaine Sanchez.)
But thankfully, there are safeguards. Covidien recently launched the Optistar Elite contrast delivery system. The new system is designed to inject contrast media-related drugs into a patient’s vascular system when used with MR imaging equipment. The company said the system’s new features, when combined with Covidien’s Ultraject prefilled syringes, are designed to help reduce the potential of certain medication errors and to help enhance efficiency.
Clinicians and manufacturers alike need to be more vigilant when it comes to reducing medical errors in the imaging and nuclear medicine arena. Patients are already vulnerable in so many ways—from lack of insurance, access to quality care, and so on. Medical imaging professionals cannot afford to fail their patients through medical errors. Make no mistake about it; mea culpa simply won’t cut it.
Marianne Matthews, editor
