Article Figures & Data
Figures
- FIGURE 1.
At its simplest, basic RCA involves 4 steps.
- FIGURE 2.
Because sentinel events happen in health-care settings involving multiple people and steps, RCA process is more involved than basic RCA.
- FIGURE 3.
Initial flowchart for misadministration demonstrates facts surrounding situation in which technologist administered bone scan dose instead of liver scan dose.
- FIGURE 4.
Effect and potential causes of misadministration of bone dose instead of liver dose are demonstrated in this fishbone diagram. Each probable cause has multiple reasons or contributing factors.
- FIGURE 5.
Initial flowchart for patient’s falling off scanner table describes facts related to this sentinel event. These facts are used to stimulate questions for investigation and to create event story.
- FIGURE 6.
Event story flowchart adds factors contributing to patient-fall sentinel event, as determined during RCA.
- FIGURE 7.
Effect and potential causes of, and contributing factors to, patient’s falling off scanner table are demonstrated in this fishbone diagram.
Tables
Procedure stage Opportunities for error Staff involved Scheduling Single vs. multiple-day procedures; procedures with delay between injection and imaging Scheduler/referring physician Screening Scan appropriateness, medication interference, pregnancy/breastfeeding Nuclear medicine physician Patient preparation Medications (prescribed and over counter), NPO status, hydration, caffeine avoidance, oral contrast agent (barium), intravenous contrast agent (iodinated) Scheduler/technologist Radiopharmaceutical administration Correct radiopharmaceutical, amount, route, and timing Technologist Special techniques Stress testing, injections in other departments (e.g., surgery) Technologist/stress test personnel/other physician Image acquisition Collimator; energy window; matrix size; acquisition type (e.g., static vs. dynamic); planar vs. SPECT, SPECT/CT, or PET/CT; positioning; technical quality Technologist Image processing and display Region-of-interest placement, image summation, filtering, reference database comparison, archiving Technologist Interpretation and reporting Misdiagnoses, missed pathology, incomplete reporting, delayed reporting Nuclear medicine physician NPO = nothing by mouth.
Procedure stage Opportunities for error Staff involved Scheduling Single vs. multiple-day therapies; radioisotope availability Scheduler/referring physician/nuclear medicine physician Screening Therapy appropriateness, medication interference, pregnancy/breastfeeding Referring physician/nuclear medicine physician/physicist Consult Pretreatment history, laboratory and other diagnostic testing results, patient factors (e.g., breastfeeding, incontinence, inability to swallow), and home environment Patient/family/nuclear medicine physician Patient preparation Preparation length (e.g., few days to weeks), medications (prescribed and over counter), NPO status, hydration, oral contrast agent (barium), intravenous contrast agent (iodinate) Scheduler/technologist/nurse/nuclear medicine physician Time-out/radioisotope administration Correct patient, therapy, radioisotope, amount, route, and timing; complete dose administration Technologist/authorized user/nuclear medicine physician Posttherapy Imaging and timing, medical and radiation safety instructions Technologist/nuclear medicine physician NPO = nothing by mouth.
