Patient Safety Issues in Radiology – Part Two

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A Two-Part Series on Workplace Stress, Burnout, and the Risks to Patient Safety.

By Dr. Cheryl Turner, Director of Global Education and Training at Legion Healthcare Partners; and founder of Rad-Cast, the CE Podcast for Rad Professionals.

Editor’s Note: Today’s blog is one of a series about the patient experience in radiology. On May 19, we published Part One of Patient Safety Issues in Radiology. Now in Part Two, the author shares real-life examples of adverse patient experiences in radiology. Be sure to check back on June 16 when we publish a new blog on Radiology’s Role in the Patient Experience written by Brigham and Women’s Hospital.

Root causes in adverse patient experiences in radiology

In the second part of our series on workplace stress and patient safety, we are going to delve into real-life examples of adverse patient experiences, including mis-administration of radiation and more serious sentinel events. Oftentimes, we find that the root causes of these incidents are human error, miscommunication, and inadequate training and policies. Although radiation accidents are rare, it is important for us all to remember that they do occur … we must also never forget that we do an incredible amount of good with our knowledge and expertise.

In 2010, the New York Times ran an investigative piece titled “Radiation Offers New Cures, and Ways to Do Harm.” ¹ In this article, author Walt Bogdanich scrutinized radiation therapy accidents that had resulted in the deaths of two patients in New York, while also noting the overdosage of radiation to patients in Florida and in Pennsylvania. The article states that the fast-changing complexity of linear accelerators has “created new avenues for error through software flaws, faulty programming, poor safety procedures, or inadequate staffing and training.”

Bogdanich reported that there were 621 radiation therapy errors in New York during the years between 2001 and 2008. Almost half of the mistakes involved delivery of radiation to the wrong body part or intended target. Records of radiation misadministration indicated that “inadequate staffing and training, failing to follow a good quality-assurance plan, and software glitches have contributed to mistakes that affected patients of varying ages and ailments.” ²

Similarly, in 2014 a patient at Auckland Radiation Oncology Limited in New Zealand received three times the prescribed dose of radiation during the treatment of bone metastasis from prostate cancer. An investigation into the accident revealed that “a stressful working environment” was the root cause of the incident, noting that employees were overworked and the department was understaffed. ³

Though radiation therapy accidents are often more catastrophic, errors with the potential for patient harm occur throughout the radiation sciences. In 2009, the Pennsylvania Patient Safety Authority reported 652 events in radiology. Half of the incidents were related to a wrong test or procedure being performed on a patient; one third of the errors involved the wrong patient being imaged; and the other 20% were attributable to the incorrect anatomical site being targeted. The majority of wrong events transpired in the radiology spectrum, with computed tomography, magnetic resonance imaging, and mammography also contributing to the total.

The report of findings from the Pennsylvania article stated that departments were experiencing a “shortage of fully prepared people, a shortage of experience people … and a shortage of dollars for upgrades, equipment, and additional staff.” The report went further to explain that a department suffering from a “lack of experienced staff means that there are not the role models, preceptors or mentors needed” to foundationally support and grow a working team. ⁴

Looking specifically into MRI errors, a 2017 UK study stated that while direct harm to staff or patients from MRI is generally low, most often an occurrence is the result of a series of failings caused by procedural breakdown or a human error, which are ultimately preventable. The report noted that the usual root causes for MRI errors were related to misunderstanding of safety policies, inappropriate safety training, ineffective communication, and overworked departments and staff. ⁵

Working conditions and departmental culture can contribute to radiation errors

A consensus from the reports, regardless of modality, refers to working conditions and departmental culture as potential causes of radiation errors which may lead to patient harm. Some of this detrimental workplace culture may be attributed to the concept of patient throughput. The model of productivity over patients has taken a costly toll on the well-being of providers and the safety of patients. The authors of the report of Task Group 100 of the American Association of Physicists in Medicine (AAPM) found that “errors that occur are not due to failures in devices and software, rather failures in workflow and process.” ⁶ It was noted that these types of failures include lack of standardized procedures, lack of communication, inadequate training, human failure (failure to review work), and a lack of staff (defined as rushed processes, lack of time, or staff fatigue). A quote from a participant in my own research summed this up with “twelve hours is a lot and I know I am up and going and I’m not tired, but I think the whole mental stress and what goes through a therapist’s head all day long on all of the patients and the number of patients just increases.” ⁷

What all is going through your head daily as you try and juggle the mental, emotional, and technical aspects of your job? Do you find yourself thinking about the exhaustion, the next patient, this current crisis, a possible furlough, the emotional drain, your own family issues, a patient’s story, the lack of support from administration, the possibility of causing an accident? Are you being asked to do too much with too little? These are the things that we, as professionals, must admit to ourselves and to our leaders.

Safe patient care requires that we be of a strong mindset in a strong culture so that we may deliver on our extensive skill set. A statement by the Radiological Society of North America (RSNA) relayed their thoughts on workplace environment when they referred to the impact of a fair and just culture which serves to “improve patient safety by empowering employees to proactively monitor the workplace and participate in safety efforts in the work environment.” ⁸ Better radiation sciences professionals will equal better patient care. This means that when we are better respected, better attuned, and better prepared, we will be in a better place – mentally and physically- to deliver the absolute best care that we are equipped to provide. We have a professional responsibility to be our best selves and to advocate for best practices in radiology and radiation therapy.

Read Part One of Patient Safety Issues in Radiology.

Dr. Cheryl Turner has been a radiation therapist for over 30 years and an educator for 15 of those years. Cheryl currently serves as the Director of Global Education and Training at Legion Healthcare Partners and is the founder of Rad-Cast, the CE Podcast for Rad Professionals. She has extensive involvement in professional societies including the American Registry of Radiologic Technologists, American Society of Radiologic Technologists, the Joint Review Committee on Education in Radiologic Technology, Association of Educators in Imaging and Radiologic Sciences, and the Latin American Radiology Outreach organization. Cheryl was awarded the 2018 Harold Silverman Distinguished Author award, a 2015 ASRT Foundation Scholarship for continued education in pursuit of her doctorate degree, and the 2012 Chattanooga State Community College “Eye of the Tiger” Outstanding Educator accolade.

Learn more:

• Patient Safety Issues in Radiology: Part One
• Measuring the Patient Experience in Radiology
• Radiation Risks from Medical Imaging
• Increase Your Awareness and Understanding of Errors in Radiology
• Radiologist Burnout Can Impact Patient Care and Personal Well-Being
• Strategies to Increase Patient Satisfaction Scores

References:

1. https://www.nytimes.com/2010/01/24/health/24radiation.html
2. https://www.nytimes.com/2010/01/24/health/24radiation.html
3. https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=11904030
4. http://patientsafety.pa.gov/ADVISORIES/Pages/201809_WrongSiteRadiology.aspx
5. https://www.birpublications.org/doi/pdf/10.1259/bjro.20180006
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4985013/
7. Turner, C. S., Brown, K., Adams, R. D., Jackowski, M. (2018). “How do they do it? A description of stress and coping in radiation therapists.” Radiation Therapist, 27 (2). American Society of Radiologic Technologists.
8. https://www.rsna.org/news/2019/February/Just-Culture-Background