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RadiationSafety
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PATIENT SAFETY FIRST
Radiation Safety
DONNA S. WATSON, RN, MSN, CNOR, ARNP-BC
R
adiation is increasingly used to confirm
diagnoses; to assist with placement of lines,
prostheses, and stents; and for other medical purposes. The dose from one abdominal computed tomography is equivalent to the dose of 400
chest x-rays,1 and more than 19,500 computed tomography scans are performed daily in the United
States.2
Although rare, accidents and errors that involve
radiation exposure can occur and may be attributed
to the amount of radiation exposure or to reactions
to iodine contrast agents, including contrast-induced
nephrotoxicity.3 When used inappropriately, the
technology can result in significant errors that could
result in a patient’s disability or death. “In 2005, a
Florida hospital disclosed that 77 brain cancer patients received 50 percent more radiation than prescribed because one of the most powerful—and supposedly precise—linear accelerators had been
programmed incorrectly for nearly a year.”4 A patient with tongue cancer who was treated at a New
York hospital received a radiation overdose that
resulted in deafness, blindness, dysphagia, and
dyspnea.4
The US Food and Drug Administration (FDA)
has launched an initiative to reduce unnecessary
radiation as a result of medical imaging (Table 1).5
“The amount of radiation Americans are exposed to
from medical imaging has dramatically increased
over the past 20 years,” said Jeffrey Shuren, MD,
JD, director of the FDA Center for Devices and
Radiological Health. “The goal of the FDA’s
initiative is to support the benefits associated with
medical imaging while minimizing the risks.”1 As
a result of this initiative, health care providers
should expect to receive information about radiation safety that promotes awareness of best practices for the use of medical imaging devices, supplies information regarding clinical decision
making, and increases awareness for the public
regarding potential risks.5
PROMOTING RADIATION SAFETY
Health care providers and surgical staff members
should develop and implement procedures and protocols that emphasize risk reduction strategies to
minimize radiation exposure and enhance patient
safety. Protocols should be developed as a collaboration among perioperative team members, the facility’s radiation safety staff, and representatives from
the radiology department. AORN recommends that
policies and procedures should include, but [not
be] limited to, establishing authority, responsibility, and accountability for radiation safety; identifying measures for protecting patients and personnel from unnecessary exposure to ionizing
radiation; developing procedures for handling
and disposing of body fluids and tissue that may
be radioactive; ensuring that appropriate personnel wear radiation monitoring devices; and
scheduling radiographic testing of leaded protective devices.6(p265)
Practice settings in which the potential exists for
radiological exposure include the OR, ambulatory
The AORN Journal is seeking contributors for the Patient Safety First column. Interested authors can contact
Donna S. Watson, column coordinator, by sending topic ideas to [email protected].
doi: 10.1016/j.aorn.2010.04.012
© AORN, Inc, 2010
August 2010
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PATIENT SAFETY FIRST
TABLE 1. Initiative to Reduce Unnecessary Radiation Exposure from Medical Imaging1
The US Food and Drug Administration (FDA) is launching a collaborative Initiative to Reduce Unnecessary Radiation Exposure
from Medical Imaging, with a focus on the types of imaging procedures that are associated with the highest radiation doses:
computed tomography (CT), fluoroscopy, and nuclear medicine.
1. Promote Safe Use of Medical Imaging Devices
1.1. Establish requirements for manufacturers of CT and fluoroscopic devices to incorporate additional safeguards into
equipment design, labeling, and user training.
1.2. Partner with the Centers for Medicare and Medicaid Services to incorporate key quality assurance practices into
accreditation and participation criteria for imaging facilities and hospitals.
1.3. Recommend that the health care professional community, in collaboration with the FDA, continue efforts to develop
diagnostic reference levels for CT, fluoroscopy, and nuclear medicine procedures locally and also through a national
radiation dose registry.
2. Support Informed Clinical Decision Making
2.1. Establish requirements for manufacturers of CT and fluoroscopic devices to record radiation dose information for use
in patients’ medical records or a radiation dose registry.
2.2. Recommend that the health care professional community continue to develop and adopt criteria for appropriate use of
CT, fluoroscopy, and nuclear medicine procedures, or other procedures that use these techniques.
3. Increase Patient Awareness
3.1. Provide patients with tools to track their personal medical imaging history.
1. Initiative to reduce unnecessary radiation exposure for medical imaging [white paper]. Silver Spring, MD: US Food and Drug Administration; February
16, 2010. http://www.fda.gov/Radiation-EmittingProducts/RadiationSafety/RadiationDoseReduction/ucm199994.htm#_Toc253092884. Accessed April
19, 2010.
surgery center, physician’s office, cardiac catheterization suite, endoscopy suite, radiology department,
and interventional radiology department, and other
sites where invasive or surgical procedures may require radiological study. Following are some riskreduction strategies that focus on patient safety.
Knowledge of the Radiation
Safety Program
Perioperative nursing personnel should be aware of
and able to implement a radiation safety program
that is consistent with state regulations that govern
the use of radiation-producing equipment and material.6 Regulatory agencies provide valuable patient
safety information and risk reduction strategies to
help prevent errors.
Consider the Patient’s History of Radiation
For any procedure, the health care provider should
consider the patient’s history of radiation exposure.
Patients also should participate in their care by
keeping records of radiation exposure and making
them available to health care providers when a new
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study is ordered or a procedure is planned. Doing so
may help to eliminate repetition of unnecessary
studies and minimize excessive radiation exposure.
Determine Whether the Patient is Pregnant
When use of radiation is anticipated, the ordering
provider should assess female patients to determine
whether they are pregnant. If a patient is pregnant
and a procedure that requires radiation exposure is
necessary, then the surgeon must inform the patient
of the risk to the developing fetus and discuss special precautions determined by facility policy that
will be implemented to minimize exposure to both
the patient and the fetus.6
Lead Shielding
Facility policy and procedure will specify the individual responsible for assessing and applying lead
shielding when appropriate to protect tissue sensitive
to radiation (ie, eye, thyroid, ovaries, testes).6 The
specific policy and procedure is based on the patient
and the study to be conducted.
PATIENT SAFETY FIRST
Radiation Equipment Training
Health care professionals should be trained and
qualified on aspects of operating all radiological
equipment. Only staff members who participate in
state-approved training and educational offerings
should operate radiological equipment. This same
standard is applicable to any mobile fluoroscopy
unit.6
Policy and Procedure for Special Precautions
Guidelines for contrast administration during diagnostic, interventional, and therapeutic procedures
should have a clearly defined policy and procedure
to address special precautions regarding nephrogenic
systemic fibrosis, renal disease, and gadolinium
administration.7
Labeling Medications
Individuals who administer medication should ensure that all medications are labeled appropriately.
In addition, an individual identified in the facility’s
policy and procedure should conduct a medication
verification process to include the right patient, the
right medication, the right dose, the right time, and
the right route.8
Proper Documentation
An individual identified in the facility’s policy and
procedure should document all protective riskreduction measures taken by perioperative team
members. Documentation must include any symptoms of an untoward patient outcome, such as erythema, abrasion, bruising, blistering, or edema.6
CONCLUSION
Patient and staff member safety is a priority and a
concern for every perioperative team member. Radiation safety requires policy and procedures based on
evidence, which involves educational updates for the
perioperative team on current issues and concerns,
and staff member training on risk-reduction measures. The perioperative team is responsible for understanding the various radiological modalities, the
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risks and benefits, and risk-reduction strategies for
operating equipment safely.
References
1.
FDA unveils initiative to reduce unnecessary radiation exposure from medical imaging [news release]. Silver Spring,
MD: US Food and Drug Administration; February 9, 2010.
http://www.fda.gov/newsevents/newsroom/press
announcements/ucm200085.htm. Accessed April 19, 2010.
2. Redberg RF. Cancer risks and radiation exposure from
computed tomographic scans: how can we be sure that
the benefits outweigh the risks? Arch Intern Med. 2009;
169(22):2049-2050.
3. Roditi G. MRI contrast agent safety in renal impairment.
Clin Risk. 2009;15(2):47-53.
4. Bogdanich W. Radiation offers new cures, and ways to
do harm. The New York Times. January 23, 2010.
http://www.nytimes.com/2010/01/24/health/24radiation.
html?pagewanted⫽all. Accessed April 19, 2010.
5. Initiative to reduce unnecessary radiation exposure for
medical imaging [white paper]. Silver Spring, MD: US
Food and Drug Administration; February 16, 2010.
http://www.fda.gov/Radiation-EmittingProducts/
RadiationSafety/RadiationDoseReduction/ucm199994.
htm#_Toc253092884. Accessed April 19, 2010.
6. Recommended practices for reducing radiological exposure in the perioperative practice setting. In: Perioperative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2010:257-268.
7. Updated ACR screening recommendation on gadoliniumbased MR contract agents, renal disease patients and
nephrogenic systemic fibrosis (NSF). American College
of Radiology. July 2007. http://www.acr.org/Secondary
MainMenuCategories/quality_safety/MRSafety/
recommendations_gadolinium-based.aspx. Accessed
April 19, 2010.
8. Guidance statement: safe medication practices in perioperative settings across the life span. In: Perioperative
Standards and Recommended Practices. Denver, CO:
AORN, Inc; 2010:665-672.
Donna S. Watson, RN, MSN, CNOR, ARNP-BC,
is a senior clinical educator at Covidien, Fox Island,
WA. As an employee of Covidien, Ms Watson has
declared an affiliation that could be perceived as
posing a potential conflict of interest in the publication of this article. However, the views expressed
herein are those of Ms Watson and do not necessarily represent the views of her employer.
This column was funded through a grant from the AORN Foundation.
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