Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority Is CT a High-Risk Area for Patient Transport? T ransports to CTs (computed tomography) have been identified as high-risk situations for patient mishaps.1-3 CT was the destination of approximately the risk of a mishap. Figure 1 represents the distribu- tion of these reports to PA-PSRS by care area. 50% of the patients transported for treatment or diag- This finding supports the necessity for staff to be in nostic studies, according to Stevenson (2002), with readiness for an urgent situation, to have emergency the average time away from the unit ranging from 62 equipment immediately available, and to maintain to 95 minutes.1 Add to the volume of scans, the high vigilance while monitoring the patient in the CT scan- level of patient acuity and it is not surprising that pa- ner or until returned to their unit. tient mishaps occur in this area.4 In other reported cases, expert clinicians anticipate CT scans are not portable and are time consuming. potential patient changes and maintain a state of The patient is in an isolated situation when being readiness to the patients’ and staffs’ ultimate advan- scanned, distant from the caregivers and at risk of a tage: sudden change in condition as the following cases submitted to PA-PSRS indicate: Patient accompanied to CT by the critical care nurse. Crash cart brought to area. Pa- Patient “coded” after completion of the CT tient’s heart stopped prior to getting injected. scan. Code unsuccessful; patient expired. Patient was successfully resuscitated. Patient was being taken off CT table after Patient was post open heart surgery and completion of CT of head when it was noted valve repair. Remained in critical condition, that patient did not appear the same as when on a ventilator and required a tracheostomy. he was brought in or while the scan was be- Physician ordered a head, neck and chest ing done. Code called. ER doctor came im- CT. The patient was accompanied to CT by mediately. Compressions were done. Pulse the critical care nurse. A crash cart was checked. Code team took over. brought to the area as a precaution. Prior to injection the patient's heart stopped. The pa- Patient had surgery and continued to com- tient was resuscitated and returned to the plain of pain. CT ordered, gastrograffin con- critical care unit. sumed, test done, patient alert and oriented. On transport back to unit became unrespon- Written patient transport policies provide guidance sive in elevator. Code blue initiated. Pulse- and directives to help ensure consistently safe care less electrical activity noted on monitor. Pa- for all patients requiring transportation, and they serve tient expired. as a starting point for efforts to improve care. Such policies can help to eliminate any guesswork associ- A review was done of the reports of cardiac arrests in ated with orchestrating a move involving oxygen PA-PSRS where patients were away from the unit for equipment and multiple personnel.5-7 CT scan, MRI, radiologic exams, or procedures sup- ported by radiology such as arteriograms. The data from PA-PSRS are consistent with the literature; the CT scan clearly stands out as a location where emer- This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 2, No. 3—Sept. 2005. The Advisory is a publication of the Pennsylvania Patient gent situations occur. Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). National hospital data indicates that the number of CT Copyright 2005 by the Patient Safety Authority. This publication may be re- scans are three and a half times more frequently per- printed and distributed without restriction, provided it is printed or distributed in formed then MRI scans.4 The high volume of CT its entirety and without alteration. Individual articles may be reprinted in their scans together with the time necessary to complete entirety and without alteration provided the source is clearly attributed. the scan expose the already compromised patient to To see other articles or issues of the Advisory, visit our web site at www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2005 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) Is CT a High Risk Area for Patient Transport? (Continued) Figure 1. "Codes" by Imaging Care Area 45% 40% 35% Percentage of Cases 30% CT Scan - 18 25% MRI - 9 20% Radiology - 8 15% Interventional - 8 10% 5% 0% n = 43 Cases Notes 5. Caruana M, Culp K. Intrahospital transport of the critically ill adult: a research review and implications. Dimensions of Critical 1. Stevenson VW, Haas CF, Wahl WL. Intrahospital transport of the Care Nursing 1998 May-Jun;17(3):146-56. adult mechanically ventilated patient. Respiratory Care Clinics of North America 2002 Mar;8(1):1-35. 6. Lovell MA, Mudaliar MY, Klineberg PL. Intrahospital transport of critically ill patients: complications and difficulties. Anesthesia and 2. Weg J, Haas C. Safe intrahospital transport of critically ill venti- Intensive Care 2001 Aug;29(4):400-5. lator dependent patients. Chest 1989 Sept:96(3):631-5. 7. Beckmann U, Gillies DM, Berenholtz SM, et al. Incidents relating 3. Smith I, Fleming S, Cernaianu A. Mishaps during transport from to the intra-hospital transfer of critically ill patients. Intensive Care the intensive care unit. Critical Care Medicine 1990 Mar;18(3):278- Medicine 2004 Feb;26(30):1579-85. 81. 4. Internet Citation: HCUPnet, Healthcare Cost and Utilization Pro- ject. Agency for Healthcare Research and Quality, Rockville, MD. [online] 2003 [cited 2005 Aug 29]. Available from Internet: http:// www.ahrq.gov/HCUPnet/. Page 2 ©2005 Pennsylvania Patient Safety Authority Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 2, No. 3 (Sept. 2005) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. ©2005 Pennsylvania Patient Safety Authority Page 3