Study on medication error rates in radiology facilities inaccurate and irresponsible

The ACR works for the day when all medical errors are eliminated and welcomes input from all medical organizations. However, the recent United States Pharmacopeia (USP) study regarding medication error rates in medical imaging facilities is incomplete, inaccurate, may unnecessarily alarm patients, and may cause many patients who require imaging care to mistakenly avoid getting it.

More than 2.5 billion imaging procedures were conducted during the 5 year (2000-2004) USP study. Even taken at face value, the 2,030 errors cited in the report, of which nearly half were incorrectly attributed to radiology facilities, represent an error rate of .00008%. This rate is more than 3,700 times better than the lowest hospitalwide medication error rate (.3%) cited by a recent Institute of Medicine report on this issue.(1,2)

"Americans are many times more likely to be struck by lightning than experience any of the errors cited in the USP report.(3) There is nothing in this study, or any other I am aware of, to support claims of systemic medication handling problems inherent or unique to radiology facilities. To make these unsupported claims at a time when medical imaging care is increasingly replacing more costly and invasive techniques is not only inaccurate but irresponsible," said James P. Borgstede, MD, FACR, chair of the American College of Radiology Board of Chancellors.

The USP report is deeply flawed and misleading. Cardiac catheterization labs are listed as the areas where the highest percentage (40%) of medication errors cited in the report occurred. The report attributes all 823 errors (nearly half of the total cited) incurred in these labs to "radiology." While interventional radiology is a growing subspecialty of radiology, and the number of these procedures performed by radiologists is increasing, radiologists currently perform less than 1% of cardiac catheterization procedures nationwide.

The paper also lumps many events which may be unrelated to the actual performance of imaging procedures into its analysis. Medications that may have been ordered by physicians in other hospital departments, yet out of necessity (particularly in regards to emergency room situations), were carried out in, or in transit to, the radiology department independent of the actual imaging process were included. This methodology further skews the results of the analysis, which only attribute 1% of the total errors cited to any sentinel event.

"The massive flaws in the report's methodology and its curious failure to provide context as to the scope of any errors reported seriously undermine the study's conclusions. To make assertions of widespread errors based on this massively incorrect and misleading report, built on a microscopically small, even when incorrectly inflated, sample is seriously misleading and potentially dangerous to patient care," said ACR Chair Borgstede.

Radiologist physicians receive 4-6 years of unique, post-medical school education in the supervision, performance, and interpretation of imaging tests. This training includes radiation safety and the strong magnetic fields used in MRI, as well as the interaction of these and other forces with medication and contrast agents.

The College has previously implemented guidelines which include provisions to address the already extremely low number of medication errors that might occur in imaging departments. The ACR looks forward to working with health care organizations and governmental bodies to further address this issue.