(How to avoid disaster) Annette Jones 2012 In the past......... p I have been reasonably confident of knowing I h b bl fid t f k i right from left. In researching this talk I have come across examples which are incorrect, and some funny stories which accompany them. However However, mistakes can have horrific mistakes can have horrific consequences, like the ones we read about when y they make the news as medical misadventure. Transition from film/screen to digital‐ T iti f fil / t di it l either DR or CR. ith DR CR We have lost the ability to orientate imaging. y g g The clues we once had name label and notches on the single sided emulsion film for extremities have all gone. single sided emulsion film for extremities have all gone Orientation of images is essential to avoid critical incidents DR is particularly hazardous when it is so easy to alter the patient’s orientation on the detector. Cervical spine obliques Cervical spine obliques are a particular minefield You might say does it really matter? You might say “does it really matter?” “Surely if the patient was to have surgery for foraminal narrowing an MRI would have also been done” However.......... Patient may have gone to the GP for left arm pain The doctor has to decide whether the pain is cardiac or cervical spine in origin. i l i i i i If the obliques are reversed the foramina on the left side might look fine and the patient has the inconvenience of g having to see a cardiologist unnecessarily. For some of us knowing which is left and which is right is easy hi h i i h i For others‐ including me, I have to really think, For others including me I have to really think especially when the patient is in an unusual position. Please, if you have a pen and paper try this simple test. With each image shown write down left or right and we will find just how easy‐ ill fi d j t h or hard it is to make a h d it i t k mistake. The image cannot be display ed. Your computer may not hav e enough memory to open the image, or the image may hav e been corrupted. Restart y our computer, and then open the file again. If the red x still appears, y ou may hav e to delete the image and then insert it again. No. 1: No. 2: No. 3: N No 3 No No. 5: 5 N No 5. No. 6: No. 7: N No 7. No. 8: N 8 No 8. No. 10: N No 10. No. 11: N No 11. N No. 12: N No. 13: N No 13. 1 Left 2 Left 3 Right 4 Left 5 Ri h Right 6 Left 7 Left 8 Right 9 Right 10 Left 11 Left 12 Right 13 Right How well did you do? y Top Back F t Front Bottom Looking back at the previous slide you can see that PA Chest g p y has been selected Therefore the machine expects the patient to be in the PA position. In the heat of the moment‐ h h f h trying to get an image, before b f the patient sinks forward or sideways, it is easy to forget to change to an AP chest setting. g g The image you acquire will be back to front and your only proof of what happened will be your lead marker. proof of what happened will be your lead marker Even if the position of this also was incorrect it will alert you to a problem. bl How many of you have seen one of these? f th ? As part of my research for this presentation.... As part of my research for this presentation I reviewed 259 oblique cervical spine examinations Images were acquired on GE digital or Kodak, Toshiba, Fuji or Agfa CR‐ (I found issues with all modalities) Results: 7 examinations that were labelled so badly it was impossible to figure out their laterality. 54 had markers added post processing so may have been 54 p p g y correct‐ or not! This gave 20% of patients who MAY OR MAY NOT have correct reports Check list: Correct patient correct body part clearly label your image with a lead letter appropriately placed BEFORE i l l d BEFORE you expose. Remember: In a court of law post processing p p g doesn’t count. IF all you take from this is how annoying I was droning on about letters just maybe it will prompt you to be careful and ALWAYS use them!
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