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Errors in administration of radiopharmaceuticals (NM specific)

 

MRTs consider patient safety, patient care, quality control and personal integrity in response to administration errors

 

+ Types of errors

  • Possible errors in administration of radiopharmaceuticals include:1-3
    • Administration of the incorrect radiopharmaceutical
    • Administration to the incorrect patient
    • Unintended route of administration, including infiltration or interstitial injection
    • Incorrect administration technique (i.e., bolus vs. slow injection)
    • Administration of a dose differing from the prescribed dosage by more than 10%

 

  • Causes for errors in administration include:4
    • Communication errors
    • Failure to follow established processes
    • Improper patient identification
    • Stressful environment
    • Improper or inadequate labeling
    • Inadequate or out-of-date training
    • Responsibilities not clearly defined

+ Addressing errors in administration of therapeutic radiopharmaceuticals

  • If the error relates to the administration of a therapeutic radiopharmaceutical, the radiologist or nuclear medicine physician is contacted for consultation on the best course of action.
  • Follow the proper procedures for incident reporting (see Incident reporting tab below).

+ Addressing errors in administration of diagnostic radiopharmaceuticals

  • If the error relates to the administration of a diagnostic radiopharmaceutical, decisions about course of action need to consider the potential adverse effects for the patient resulting from the primary error and its consequences (such as unjustified exposure, delayed diagnosis, increased costs, increased workload, reduced confidence, etc.)
  • The actions taken also vary depending on the type of error:
    • Incorrect radiopharmaceutical
    • Incorrect dose
    • Incorrect route of administration


Incorrect radiopharmaceutical


  • The patient is rescheduled as soon as possible to avoid further delay of diagnosis.
  • Patients are encouraged to eliminate the radiopharmaceutical:4
    • Depending on the radiopharmaceutical administered, instructions are provided for expeditious elimination (i.e., hydration and frequent voiding)
    • A radiologist or nuclear medicine physician may need to be consulted
    • If appropriate, blocking agents are used to diminish the absorbed dose to the thyroid gland, salivary glands and stomach


Incorrect dose or unintended route of administration


  • If possible, the diagnostic study is obtained without the administration of additional activity.
    • If a diagnostic study cannot be obtained, the lowest possible additional activity (top up) which will still produce a diagnostic study is administered
    • Departmental policy is always consulted for additional information regarding the administration of additional activity

 

  • If the error in administration cannot be amended and the result is an incomplete study, the patient is rescheduled as soon as possible to avoid further delay of diagnosis.
  • Follow the proper procedures for incident reporting (see Incident reporting tab below).

+ Incident reporting

  • MRTs promptly investigate and report all incidents where (also see Patient safety incident reporting guideline):2   
    • Radiopharmaceutical has been delivered to the wrong patient
    • Radiopharmaceutical has been delivered by the wrong route
    • The wrong radiopharmaceutical has been administered
    • The administered activity differs substantially from the prescribed activity

 

  • Once an error in administration has occurred, the following persons are notified:5
    • Departmental supervisor
    • Radiologist or nuclear medicine physician currently reporting in the department
    • Patient and/or caregiver (after consulting with the referring physician)
    • Radiation Safety Officer (depending on department practice)

 

  • MRTs follow the communication path and policies established by the institution
  • A written description of the event is prepared and includes:
    • A description of the incident by those involved and its cause5
    • All records of radiopharmaceutical involved6
    • A record of all persons involved7
    • In some cases, the estimates of the organ doses and/or effective doses received and the methods used to generate the estimates (i.e. pregnancy, misadministered therapy dose)5,8
    • If there is potential for patient detriment, the subsequent medical consequences for exposed individuals
    • Recommendations on how to prevent recurrence5

+ Patient follow up

  • It is important to put patients needs first following an error in administration.
  • Errors in administration are explained to the patient and/or family, and questions are answered (also see Disclosure of harmful incidents guideline).
  • Efforts are made to ensure that delays to a patient’s diagnosis and care are minimized:
    • Patients are rescheduled with priority status if a repeat procedure is required
    • The patient’s preference for appointment date/time is taken into account when rescheduling

+ Departmental follow up

  • MRTs take steps to ensure that errors in administration are not repeated in the future:4
    • Information gathered from the investigation helps to identify the cause to prevent similar events from occurring again
    • A culture of safety is encouraged, with education on the incidents and training on prevention measures

+ References

  1. United States Nuclear Regulatory Commission. NRC Regulations Title 10, Code of Federal Regulations, Title 10, Volume 1, Chapter 1, Part 35 10CFR35.2075.
  2. International Atomic Energy Agency. Safety Series. International Basic Safety Standards for Protection Against Ionizing Radiation and for the Safety of Radiation Sources. Available at: http://www-pub.iaea.org/mtcd/publications/PubDetails.asp?pubId=5202. Accessed May 3, 2013.
  3. National Council on Radiation Protection and Measurements (NCRP). Misadministration of Radioactive Material in Medicine - Scientific Background: (Commentary No. 7). Available at: http://www.ncrppublications.org/Commentaries/07. Accessed February 21, 2013.
  4. International Atomic Energy Agency. IAEA Training material on radiation protection in nuclear medicine, Part 11: Potential exposure and accidental medical exposure. Available at: http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=2&ved=0CC4QFjAB&url=http%3A%2F%2Frpop.iaea.org%2FRPOP%2FRPoP%2FContent%2FDocuments%2FTrainingNuclearMedicine%2FLectures%2FRPNM_Part11_potential_exp_WEB.ppt&ei=lG42ULPnF_DyyAH2r4D4Bw&usg=AFQjCNEyJDCVwuTYB6eo2HL20LJoExTJcw&sig2=iFNzivQeACM5Zhr5VmNHPg. Accessed February 21, 2013.
  5. Government of Canada. Justice Laws Website. Radiation Protection Regulations. Available at: http://laws-lois.justice.gc.ca/eng/regulations/sor-2000-203/page-1.html#docCont. Accessed February 21, 2013.
  6. Government of Canada. Justice Laws Website. General Nuclear Safety and Control Regulations s 27. Available at: http://laws-lois.justice.gc.ca/eng/regulations/sor-2000-202/page-1.html. Accessed February 21, 2013.
  7. Government of Canada. Justice Laws Website. Nuclear Safety and Control Act s 24. Available at: http://laws-lois.justice.gc.ca/eng/acts/N-28.3/page-7.html. Accessed February 21, 2013.
  8. Canadian Nuclear Safety Commission. Ascertaining and Recording Radiation Doses to Individuals. G-91. Available at: http://nuclearsafety.gc.ca/pubs_catalogue/uploads/44019-G91E.pdf. Accessed February 21, 2013.

 

Validation

May 8, 2013

 

 
Canadian Association of Medical Radiation Technologists
85 Albert St, Suite 1000, Ottawa, ON, K1P 6A4
phone: 613 234-0012 / 800 463-9729
fax: 613 234-1097
www.camrt.ca