Analyzing a Series of Events in the Radiology Department - Essay Example

?Main report The aim of the present paper is to critically analyze the series of events that occurred, involving Karemore Best Health NHS Trust and St. Patchup Hospital NHS Trust with the death of Mrs. Wanda Doff, with consideration of guidelines and policies of health institutions, specifically with the radiology department. It follows with a series of recommendations for change to avoid such mishap from recurring at the two hospitals. This would also serve as a reminder towards other health care institutions towards strict compliance of standard procedures, and a guide to prevent such accident to occur in their organization. As requested by the Chief Executives of both Karemore and St. Patchup Hospitals, the author of the present report is a Radiology Services Manager of a hospital outside Prosperham City. Summary The persons directly involved in the unfortunate circumstance are: (1) Mrs. Wanda Doff, the patient, (2) Di Gital, a radiographer employed at St. Patchup from an agency, (3) Karl Amity, a radiographer at Karemore who took the patient’s radiology exams, and (4) Dr. Penny Drops, anesthetist at Karemore involved in Mrs. Doff’s operation. Mrs. Doff died of respiratory and cardiac arrests in the middle of a hip replacement operation at Karemore Hospital. Due to complaints of right hip pain approximately 6 months before the operation, Mrs. Doff underwent a chest radiograph antero-posterior (AP) position at St. Patchup Hospital, which was conducted by Di Gital. Unavailability of spare batteries for the hoist prompted the latter to escort the patient all by herself towards and off the examination table, but hurt herself in the process as her body twisted. Several months later the patient was accidentally knocked off by a group of skateboarding teenagers who called an ambulance upon realizing that she cannot stand. Admission at Karemore Hospital subjected Mrs. Doff to several radiograph testing due to inappropriate centring, which were conducted by Karl Amity, and thus resulted to excessive radiation dosage. Images showed subcapital fracture of the right neck of femur. During assessment before the surgical procedure, Dr. Penny Drops noted the patient’s difficulty of breathing and increasing temperature, thus ordered another chest x-ray. That same evening, Karl Amity once again conducted the examination but mixed up results of the said patient with another. Seeing that the results were normal, Dr. Drops agreed that Mrs. Doff could go into the theatre and proceeded with the operation. Complications aroused, however, leading the patient into respiratory and cardiac arrests where practitioners were not able to resuscitate her. Range of Incidences and Mistakes Upon investigating the incident, it can be traced that lapses started with the imaging departments of both Karemore and St. Patchup Hospitals. Initially looking at St. Patchup Hospital, the lack of supplies - in this case batteries for the hoist - triggered the sole personnel left in the room, Di Gital, to aid Mrs. Doff. This, however, is not an excuse since patient safety is always a priority, and Di Gital should have realized the risk placed upon the patient in the process of lifting her alone. Furthermore, several other lapses are perceived from Karemore Hospital. Taking into consideration that Karl Amity has been a qualified radiographer for several years, it is expected that he knows how to conduct the procedures adequately and follow given protocols. However, the patient was exposed to excessive radiation dose because of Mr. Amity’s mistakes with centring and lateral hip projection. Dr. Drops also committed a mistake in the act of ordering another chest x-ray without reviewing the patient’s records which could have revealed all the previous examinations she has undergone. Additionally, Karl did not question the doctor’s order for another x-ray even in the knowledge that he has met the patient earlier that morning. To make matters worse, he interchanged the results of the patient with another woman’s, thereby giving wrong results to both patients. Lastly, thorough assessment could have been performed in the incongruence of imaging results with the signs presented by Mrs. Doff before proceeding with the surgical procedure. Recommendations The World Health Organization (WHO) presents that “an incorrect diagnosis, or treatment in the absence of any diagnosis, can have serious, even fatal consequences for the patient,” (p. 1) and it is therefore important that there be a precise and accurate diagnosis, achieved through competent health providers and reliable medical procedures. A diagnostic imaging is a “means to take pictures of the structure and processes in the body and make them visible or “accessible” to the human eye,” but the WHO perceives this as a problem as this is not accessible by the entire population, or if it is, “both the quality and safety of the procedures may be questionable or even dangerous” (pp. 1-2). Certain procedures and policies are established in every institution and there are several things to be considered, such as the presence of a radiation safety officer, certification and licensing of staff, radiation protection, and informed patient consent (Lister, 2010). All these aspects aim towards quality and safe health care provision. Radiology departments of many health institutions and organizations envision to provide excellent medical imaging, optimize the use of traditional and emerging technologies in the pursuit of optimal care to patients, and contribute to the application of biomedical imaging (Stony Brook University Medical Center, 2009; University of Alabama at Birmingham, 2009; University of Washington, n.d.). With the same vision applied to St. Patchup and Karemore hospitals, there would be greater efforts to improve their own radiology departments. Manuals, standard communication, and outline guides are available for health institutions to adapt in their specific radiology departments (Miller & Wheeler, 1981; University of Utah, 1996; Utah State Hospital, 2001; Canadian Association of Radiologists, 2010). Reorganization of the radiology departments of both hospitals involved in the incident could highly benefit both patients and the entire health care team. This would include amendment of present policies, conducting more trainings and workshops for members of the team, adequate supplies and manpower, and systematized and organized patient records. Emphasis on developing a “culture of safety” within the department would effectively manage risks (Johnson & Kruskal, 2010). The Picture Archiving and Communications Systems (PACS) is an increasing trend in the field of radiology. Redfern et al. (2000) conducted a study to evaluate workflow changes and efficiency after introducing PACS and gathered that efficiency is dependent on patient volume, and workflow improvements are due to a shift from batch to on-line reading that is enabled by the ability of the system to route enough examinations to keep radiologists fully occupied (p. 97). The primary benefit from using PACS is that clinicians outside the radiology department will have more efficient access to the images (Ratib, 1997). Although there have been contentions with its application, Steckel (1994) had argued that the system could give utmost help in health care delivery. It is noted that during the time the incident occurred, Karemore Hospital had recently updated their PACS. If the clinicians involved with Mrs. Doff had utilized the availability of such system, death of the patient could have been avoided. It is also essential to note that the National Institutes of Health (NIH) encourages the use of software that tracks the patient’s radiation dose and document it in the his or her records, and implement this policy in all medical imaging facilities (Bluemke & Farooki, 2010; Neumann & Bluemke, 2010). Conclusion The present report summarizing the case of Mrs. Doff, analyzing the range of mistakes incurred at St. Patchup and Karemore hospitals, and presenting recommendations based on policies, was written to aid the said institutions and others as well, in handling similar cases. There is thus a call for review and modifications in the present systems of both hospitals to improve patient safety in care delivery. References Bluemke, D. A., & Farooki, S., 2010. NIH adopts radiation exposure tracking policy. [Online] Available at: http://www.rsna.org/Publications/rsnanews/May-2010/NIH_feature.cfm [Accessed 23 March 2011]. Canadian Association of Radiologists, 2010. CAR standard for communication of diagnostic imaging findings. [Online] Available at: http://www.car.ca/uploads/standards%20guidelines/20101125_en_standard_communic ation_di_findings.pdf [Accessed 23 March 2011]. Johnson, C. D., & Kruskal, J. B., 2010. “Culture of safety” minimizes risk. [Online] Available at: http://www.rsna.org/Publications/rsnanews/May-2010/safety_feature.cfm [Accessed 24 March 2011]. Lister, J., 2010. Radiology policies and procedures. [Online] Available at: http://www.ehow.com/list_7154340_radiology-policies-procedures.html [Accessed 24 March 2011]. Miller, R. M., & Wheeker, W. W., 1981. Something new: a radiology policies and procedures outline guide. Radiology Management, 3(4), pp.35-38. Neumann, R. D., & Bluemke, D. A., 2010. Tracking radiation exposure from diagnostic imaging devices at the NIH. Journal of the American College of Radiology, 7(2), pp. 87-89. Ratib, O., 1997. From PACS to the world wide web. [Online] Available at: http://www.hon.ch/Library/papers/ratib.html [Accessed 24 March 2011]. Redfern, R. O., et al., 2000. Radiology workflow and patient volume: Effect of picture archiving and communication systems on technologists and radiologists. Journal of Digital Imaging, 13(2), pp.97-100. Steckel, R. J., 1994. The current application of PACS to radiology practice. Radiology, 190, pp.50A-54A. Stony Brook University Medical Center, 2009. Department of radiology. [Online] Available at: http://www.stonybrookmedicalcenter.org/radiology/ [Accessed 24 March 2011]. University of Alabama at Birmingham, 2009. Welcome to the UAB department of radiology. [Online] Available at: http://medicine.uab.edu/radiology/ [Accessed 24 March 2011]. University of Utah, 1996. Radiation Safety Policy Manual. [Online] Available at: http://www.rso.utah.edu/policies/rsm.pdf [Accessed 23 March 2011]. University of Washington, n.d. Department of radiology. [Online] Available at: http://www.rad.washington.edu/ [Accessed 24 March 2011]. Utah State hospital, 2001. Utah state hospital policies and procedures radiology. [Online] Available at: http://www.hspolicy.utah.gov/USH/pdf/radiology.pdf [Accessed 22 March 2011]. World Health Organization, n.d. Essential diagnostic Imaging. [Online] Available at: http://www.who.int/eht/en/DiagnosticImaging.pdf [Accessed 22 March 2011]. Read More