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Error Rate Greatest In Hospital Radiology
Study Cites Communication Failures

By Rob Stein
Washington Post Staff Writer
Wednesday, January 18, 2006

One of the most dangerous times in the hospital for patients is when they are wheeled out of their rooms and taken to the radiology department for a test or a procedure, according to report being released today.

Medication errors that harm patients are seven times more frequent in the course of radiological services than in other hospital settings, according to the analysis by the United States Pharmacopeia, a nonprofit group that sets standards for the drug industry.

"Whenever a patient is moved from one location to another, the patient should ask where they are going and why," said John P. Santell of the organization's Center for the Advancement of Patient Safety, who helped prepare the study. "Our report shows this is when the risk is particularly great."

The researchers said they hope the findings will prompt hospitals to examine the problem, find ways to minimize errors and let patients and their loved ones know they should be alert to mistakes at such times.

"We hope that this report is a call to action," Santell said.

There are a variety of reasons that harmful errors are much more likely in the radiology suite. These include the fact that patients often receive potentially dangerous drugs such as dyes, sedatives and blood thinners, and their care is being handed off from one department to another, creating the opportunity for communication failures, the researchers said.

"The errors often occur in the transfer of information," Santell said.

The findings are especially significant because the number of radiological procedures being performed is increasing, Santell said.

In addition to X-rays, radiology departments perform a wide array of tests and procedures, such as cardiac catheterization and diagnosing heart problems.

Other experts said the findings were surprising and important, because this area has not received a lot of attention in recent efforts to minimize medical errors.

"I don't think anyone really recognized how much of a problem this really is," said Michael Cohen, president of the Institute for Safe Medication Practices in Huntingdon Valley, Pa., which studies drug errors. "Every hospital in the United States ought to be taking a look at this. This is important."

Others, however, said the report created the false impression that such tests and procedures are particularly dangerous by lumping together all errors that occurred in the radiology department, even if the errors had nothing to do with a radiological exam. Even including those, the risk is "minuscule," said James P. Borgstede of the American College of Radiology, noting that more than 570 million procedures are performed each year.

"We certainly are concerned about any kind of patient errors, and we don't want any errors at all," Borgstede said. "The big concern that I have is this may cause unnecessary fear in patients, and patients may therefore avoid needed examinations."

For the report, Santell and his colleagues reviewed 823,268 medication errors that were voluntarily reported by 315 hospitals between 2000 and 2004. The researchers identified 2,032 errors that occurred in radiology departments. Of those, 12 percent resulted in some kind of harm to patients, which is seven times higher than the percentage of hospital medication errors that caused harm overall, or 1.67 percent, Santell said.

"So even though the volume of errors is low, the risk of harm is high," he said.

Many of the errors resulted from communication breakdowns, the researchers found, such as passing on incorrectly the dose or name of the drug being administered, or one worker failing to inform another about other drugs a patient was taking. The most common errors were patients getting the wrong dose or drug, failing to get the drug they should have had or having the drug administered incorrectly, Santell said.

He said the findings, based on voluntary reporting, probably underestimate the problem.

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