Medication Safety Officer Research Articles

Development of an innovative approach to predict and reduce the patient radiation dose risk in interventional cardiology

Introduction This study aims at identifying the high-dose procedures in a cardiology department and to find correlation factors to predict the risk of occurrence of deterministic effects in terms of relevant indicators. Materials and methods A working group composed of medical physicists, interventional cardiologists and Radiation Safety Officer was created. DOSITRACE platform, allowing automated data collection and historical patient dosimetry was installed. A couple of approaches have been implemented: a risk management approach that is oriented toward a prevention-based perspective and another risk management approach that is oriented toward a curative-based perspective. Results The use of DOSITRACE in clinical routine has enabled us to identify the recanalization of Chronic Total Occlusion (CTO) as the one which may deliver the highest patient radiation dose. Subsequently, the working group has become interested in this procedure to figure out the factors that determine the escalation of the radiation dose delivered to the patient. The results are as follows: ● An average reduction of 15% of the radiation dose delivered to the patient through a process of optimization of the dose was obtained. ● A correlation between the BMI, the beam angulation and patient radiation dose was found. ● For the procedure for recanalization of CTO, an increase in dose in terms of the complexity factor J-CTO score was highlighted: Score = [0, 1, 2, 3, 4]: Average Dose Area Product (DAP) = [152,160,244,299,418 Gy cm2]. In parallel, the group has worked on the equivalent dose effect of the entrance skin doses delivered for the repeated interventions in order to predict the occurrence of deterministic effects due to cumulative dose. A method, published by the team Balter et al. in 2010 was implemented in DOSITRACE. For the case of the repeated recanalization of CTO, we have implemented an innovative predictive risk method depending on the J-CTO score and BMI. A radiochromic film dosimetry was implemented in a systematic manner for CTO procedures to measure precisely the maximum skin dose delivered to the patient (Peak Skin Dose PSD), a real risk indicator. Conclusion This project has enabled us to identify the high-dose procedures and to implement methods to predict the risk of deterministic effects occurring, both based on the cumulating PSD for the repeated recanalization of CTO interventions, and the J-CTO Score.

Massachusetts governor files compounding bill

to limit the number of pharmacists to 4. “The Board will include more members not practicing in the industry they are responsible for regulating,” Patrick said in a news release. But Christian A. Hartman, PharmD, MBA, FSMSO, named to chair the commission by the governor on November 1, 2012, backed the commission’s recommendations and disagreed with the governor in an interview with Pharmacy Today. “Part of the issue of how we got here is: We didn’t have the expertise on the board of pharmacy, and the proposed governor’s legislation makes it even worse.” Hartman is Director of Clinical Quality and Patient Safety at Wolters Kluwer; Principal and Director, Patient Safety and Quality, at Lucian Health; and founder and President of the American Society of Medication Safety Offi cers. Currently, according to the Massachusetts Board of Registration in Pharmacy website, 7 members of the 11-member board are pharmacists; there’s also 1 physician, 1 nurse, and 2 public members. Carmen Catizone, MS, BSPharm, DPh, Executive Director of the National Association of Boards of Pharmacy, provided national context. “The typical board of pharmacy usually consists of six to eight members,” Catizone said. “The members include pharmacists from various practice settings, such as community pharmacy and hospital pharmacy, as well as at least one consumer, nonpharmacist member.”

RPS argues that medication safety officers must be pharmacists

RPS argues that medication safety officers must be pharmacists

Network of medication safety officers planned to improve reporting of errors

Network of medication safety officers planned to improve reporting of errors

Step forward: Hospitals’ journey to ‘Just Culture’

Anyone can make a mistake, but in industries such as aviation and health care, one small mistake can lead to dire consequences and loss of life. In the past, a person who made a mistake or reported an error was punished. That is now changing, thanks to the "Just Culture" concept being pioneered by David Marx.

Drug‐related hazardous conditions to prevent injury and defining injury is also important

Pharmacoepidemiology and Drug SafetyVolume 21, Issue 11 p. 1247-1248 Letter to the Editor Drug-related hazardous conditions to prevent injury and defining injury is also important Sandra L. Kane-Gill, Corresponding Author Sandra L. Kane-Gill Associate Professor of Pharmacy and Therapeutics, and Clinical Translational Science Institute, Center for Pharmacoinformatics and Outcomes Research, Pittsburgh, PA, USA Critical Care Medication Safety Officer, Department of Pharmacy, UPMC, Pittsburgh, PA, USA S. L. Kane-Gill, Associate Professor of Pharmacy and Therapeutics, and Clinical Translational Science Institute, Center for Pharmacoinformatics and Outcomes Research, 918 Salk Hall, 3501 Terrace St. Pittsburgh, PA 15261, USA. E-mail: [email protected]Search for more papers by this authorTiffany R. Chapman, Tiffany R. Chapman Safe Medication Use Resident, Department of Pharmacy, UPMC, Pittsburgh, PA, USASearch for more papers by this authorJoseph F. Dasta, Joseph F. Dasta Professor Emeritus, The Ohio State University, College of Pharmacy, Columbus, OH, USA Adjunct Professor, University of Texas, College of Pharmacy, Texas, USASearch for more papers by this author Sandra L. Kane-Gill, Corresponding Author Sandra L. Kane-Gill Associate Professor of Pharmacy and Therapeutics, and Clinical Translational Science Institute, Center for Pharmacoinformatics and Outcomes Research, Pittsburgh, PA, USA Critical Care Medication Safety Officer, Department of Pharmacy, UPMC, Pittsburgh, PA, USA S. L. Kane-Gill, Associate Professor of Pharmacy and Therapeutics, and Clinical Translational Science Institute, Center for Pharmacoinformatics and Outcomes Research, 918 Salk Hall, 3501 Terrace St. Pittsburgh, PA 15261, USA. E-mail: [email protected]Search for more papers by this authorTiffany R. Chapman, Tiffany R. Chapman Safe Medication Use Resident, Department of Pharmacy, UPMC, Pittsburgh, PA, USASearch for more papers by this authorJoseph F. Dasta, Joseph F. Dasta Professor Emeritus, The Ohio State University, College of Pharmacy, Columbus, OH, USA Adjunct Professor, University of Texas, College of Pharmacy, Texas, USASearch for more papers by this author First published: 29 October 2012 https://doi.org/10.1002/pds.3347Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume21, Issue11November 2012Pages 1247-1248 RelatedInformation

Radiation Dose Management for Fluoroscopically Guided Interventional Medical Procedures

This report released by the National Council of Radiation Protection and Measurements (NCRP) discusses how to manage radiation doses during fluoroscopically guided interventional medical procedures. It provides recommendations and supporting information with a compendium of references on radiation dose management for patients and medical personnel during interventional medical procedures. This report was prepared by the members of the NCRP Scientific Committee 2-3 on Radiation Safety Issues for Image-Guided Interventional Medical Procedures which includes well-known scientific experts on the subject. The report is a welcome addition as it contains a wealth of information on the types of interventional fluoroscopy procedures, fluoroscopy equipment, radiation dose measurements, assessment of risks, how to manage radiation dose, and so forth. Recent surveys have shown an increasing number of fluoroscopically guided interventional procedures performed in the United States and worldwide. The procedures are often less invasive and less costly with significant benefits to patients. They are performed by radiologists, cardiologists, and other medical specialists with assistance from medical support staff. However, according to another NCRP report (160), interventional procedures now account for nearly 14% of the collective dose to the US population from among the various medical x-ray procedures and therefore warrants ways to optimize and manage radiation doses. The main purpose of the report is to provide valuable information about interventional fluoroscopy procedures and how to manage the radiation dose to both patient and staff. As aptly described in the report's preface, this report will benefit radiologists, cardiologists and other medical specialists performing fluoroscopy procedures. Those who perform fluoroscopically guided interventional procedures, but do not have sufficient training in the practical aspects of radiation protection, will find this report very useful. Medical physicists, health physicists, and radiation safety officers will find this report especially helpful in assisting their physician colleagues in developing optimal methods for managing radiation dose during interventional fluoroscopy. This report is also intended to benefit policy makers who plan to establish radiation dose management requirements for those who conduct fluoroscopically guided interventional procedures with regard to optimizing imaging protocols, managing, tracking, and trending radiation doses to patients and medical staff and credentialing and privileging physicians to use the fluoroscopic equipment for such procedures. The report follows the standard NCRP report format with an executive summary providing more than 30 recommendations with references to the sections that discuss each recommendation in detail. The report is further divided into sections organized in the following way: general information (Sec. II) that includes a list of fluoroscopically guided interventional procedures, justification, benefit-risk, physics, dosimetry and radiation biology; Sec. III on fluoroscopy equipment and facilities that includes discussion on room design and structural radiation protection and protection of patients; Sec. IV is the longest section providing details on patient dose reviews, a patient dose management program with a sample dose-management process including how to monitor patient radiation dose. This section contains a number of tables of patient radiation doses for various interventional procedures, including table (4.7) that suggests values for first and subsequent notifications for the various dose metrics available during interventional procedures. Section V deals with the protection of staff while Sec. VI covers the administrative and regulatory considerations that includes discussion on education and training, purchase, configuration and quality control followed by summary and conclusions (Sec. VII). In addition, the report consists of 13 appendices that include topics such as benefit-cost and benefit-risk analyses, physics and dosimetry, radiation injuries, equipment operations, an example for informed consent for radiation risk plus an extensive bibliography. In addition to providing thorough treatment of each of the subject areas, the report offers unique methods to implement and assess radiation protection programs in general. Overall this report is very timely and will benefit the reader in understanding various aspects of radiation protection during interventional fluoroscopy procedures. This report can serve as a valuable resource guide to anyone exploring ways to optimize fluoroscopy procedures, to establish guidelines on patient dose, dose tracking and trending, and establish education and training to those performing fluoroscopically guided interventional procedures. Medical physicists will find this report very helpful and can use this as a reference guide to assist their physician colleagues to optimize interventional procedures. I highly recommend this report to medical physicists and health physicists who are active in the area of interventional fluoroscopy and also participating in maintenance of certification (MOC) related activities. Mahadevappa Mahesh is Associate Professor of Radiology and Cardiology at the Johns Hopkins University School of Medicine and is the Chief Physicist at the Johns Hopkins Hospital, Baltimore, MD. His research interests are in medical imaging, particularly in areas of multiple-row detector computed tomography (MDCT), interventional fluoroscopy and digital mammography. He teaches medical physics related topics to medical residents, and undergraduate and graduate students.

Medication safety practices in hospitals: A national survey in Saudi Arabia

BackgroundMedication errors in hospitals are a worldwide concern. The World Health Organization has recommended the implementation of basic applications in healthcare systems to improve medication safety, but it is largely unknown whether these recommendations are adhered to by hospitals. We assessed the presence of core medication safety practices in Saudi Arabian hospitals. MethodsWe developed and validated a survey to assess medication safety practices in hospitals. Major headings included Look-Alike Sound-Alike (LASA) medications, control of concentrated electrolyte solutions, transitions in care, information technology, drug information and other medication safety practices. Trained pharmacists visited samples of hospitals from all regions of Saudi Arabia. ResultsSeventy-eight hospitals were surveyed. Only 30% of the hospitals had a medication safety committee and 9% of hospitals had a medication safety officer. Only 33% of hospitals had a list of LASA medications and 50% had a list of error-prone abbreviations. Concentrated electrolytes were available in floor stock in 60% of the hospitals. No hospital involved pharmacists in obtaining medication histories and only 37% of the hospitals provided a medication list to the patients at discharge. While 61% of hospitals used a computer system in their pharmacy to enter prescriptions, only 29% of these hospitals required entry of patient’s allergies before entering a drug order. ConclusionsCore practices to improve medication safety were not implemented in many hospitals in Saudi Arabia. In developing countries, an effort must be made at the national level to increase the adoption of such practices.

의료레이저안전관리자의 역할과 국내 적용 방안 연구

레이저 기술의 발전과 더불어 다양한 의료영역에서 레이저가 사용되고 있으며 그로 인한 위험성도 증가하고 있다. 레이저를 안전하게 사용하기 위해서는 레이저의 안전에 관한 지식을 가지고 관리할 수 있는 사람이 지정될 필요가 있다. 이에 따라 많은 나라에서 레이저안전관리자 체제를 운영하고 있다. 의료레이저안전관리자는 레이저의 안전사용과 관련하여 교육과 훈련 등의 권한과 책임을 가진다. 본 연구에서는 의료레이저안전관리자의 미국의 운영현황을 살펴보고 의료레이저안전관리자의 역할과 국내 도입 방안을 살펴보았다. According to the development of laser technology, applications of laser in medical area, and the resulting risks are increasing. To ensure the safe use of laser, it is necessary to assign a person who has the knowledge of laser safety as MLSO(medical laser safety officer). In many countries, the system of laser safety officer management is operating. MLSO has the responsibilities and duties of the operation of the laser safety program, training, and education. In this study, we analyzed the adoption of MLSO through the investigation of the MLSO management status in United States.

Overview of the Board of Laser Safety's professional certification programs for Laser Safety Officers

Abstract Laser technology has evolved as an important tool for many applications, including a variety of medical uses. The study of laser safety has similarly grown and evolved. For many advanced laser operations, ensuring the safety of people in the area of the laser requires an advanced knowledge of the arcane principles involved. The complexity of the hazards associated with many laser systems, and the unique skill set needed to effectively evaluate and implement control measures for those hazards, have created the need for organizations to clearly identify those individuals with the proficiency necessary to manage such advanced laser safety issues. To meet this need, the Board of Laser Safety (BLS) was established as a nonprofit organization affiliated with the Laser Institute of America to develop and sustain a program for safety professionals to establish and maintain recognizable competence and expertise in the area of laser safety. The BLS developed a Certified Laser Safety Officer (CLSO) program, by which individuals who have demonstrated comprehensive knowledge in the area of laser safety may designate themselves a CLSO. Shortly thereafter, the BLS created the Certified Medical Laser Safety Officer (CMLSO) program, to recognize individuals with the knowledge and expertise necessary to evaluate and control laser hazards under the special conditions that exist in the medical arena. This paper provides an introduction to the CLSO and CMLSO programs.

Principles for defining adverse events in behavioral intervention research: lessons from a family-focused adolescent drug abuse trial

Behavioral intervention research has lagged behind biomedical research in developing principles for defining, categorizing, identifying, reporting, and monitoring adverse events and unanticipated problems. In this article we present a set of principles for defining adverse events and how they were applied in a large national multi-site family therapy study for substance-using adolescents, The Brief Strategic Family Therapy (BSFT) Effectiveness Study. The BSFT Effectiveness study tested how BSFT compares to Treatment as Usual (TAU) for the treatment of drug-abusing adolescents. During protocol development, experts in the BSFT intervention, medical safety officers, ethicists and senior investigators defined the procedures for identifying, tracking and reporting adverse events for drug using adolescents as well as their family members. During this process the team identified five key guiding principles. The five guiding principles that were used for defining adverse events in this behavioral trial were that that the adverse events should be validated and plausible, and that monitoring systems should assess relatedness, be systematic, and are a shared responsibility. The following non-serious adverse events were identified: arrest, school suspension and drop out, runaway, kicked out of home and violence. The serious adverse events in this study for the identified adolescent participant and all other consented family members were physical or sexual abuse, suicidal behavior, homicidal behavior, hospitalization (drug related or psychiatric related only) and death. The methods used in categorizing, identifying and reporting adverse events in the BSFT trial are outlined. More than 50% of the adolescent population (277/481 = 57.5 %) experienced an adverse event during the trial. Family members experienced less adverse events, (61/1338 = 4.5%). The most common event for the adolescent group was arrest (164/277= 59.2%), followed by school suspension/dropout (143/277 = 51.6%), and runaway (79/277= 28.5 %). For the family member group, the most common event was violence (25/ 61 = 40.9%) followed by arrest (13/61 = 21.3%). There was a significant difference in the presence of adverse events in family members that were randomized to BSFT 44/721 (6.1%) when compared to Treatment as Usual 17/617 (2.8%) (p = 0.004). A probable explanation for this is that there were more opportunities to identify adverse events for family members assigned to BSFT because family members attended therapy sessions. This difference may also represent the risk for family members that participate in an evidence-based family intervention like BSFT. The utility of the principles outside of the BSFT trial is unknown. Based on the events reported in this trial, the efforts for monitoring and categorizing adverse events appeared justified and appropriate. The strategies and principles described in this paper may be useful for those developing safety plans for behavioral intervention research, and to family therapy researchers for assessing the safety of behavioral family interventions.

Residency program fills medication safety void

Hospitals are increasingly adding medication safety officers to their ranks, said Daniel M. Ashby, pharmacy director at Johns Hopkins Hospital in Baltimore and past president of the American Society of Health-System Pharmacists (ASHP). To meet the growing demand for practitioners skilled in medication-use safety, he said, colleges of pharmacy need to ensure that they are providing curriculum and experiential learning activities to prepare pharmacists to fill those positions. But, Ashby added, institutions should also consider sponsoring a specialty pharmacy residency program in medication-use safety to further help new practitioners develop the knowledge, skills, and abilities needed to perform the job of a medication safety officer. His hospital is doing just that. The medication-use safety residency at Johns Hopkins, a program created in collaboration with ASHP, is a postgraduate year two (PGY2) training program for pharmacists who have completed a one year pharmacy practice residency. “Johns Hopkins is an organization that has a long history of supporting residency training and, as an organization, has made a very strong commitment to advancing medication safety as one of its top priorities,” Ashby said.

WE-C-P-618-02: NRC Update: Part 35 Training and Experience and Who's ACMUI and Why Should a Medical Physicist Care?

The Nuclear Regulatory Commission (NRC) finalized the training and experience requirements for Authorized Medical Physicists, Authorized Users and Radiation Safety Officers in March 2005. A brief summary of the changes to the regulations will be presented. The Advisory Committee on the Medical Uses of Isotopes (ACMUI) was established in 1958 to advise NRC staff on policy and technical issues that arise in the regulation of the medical uses of radioactive material in diagnosis and therapy. The ACMUI membership includes health care professionals from various disciplines who comment on changes to NRC regulations and guidance; evaluate certain non-routine uses of radioactive material; provide technical assistance in licensing, inspection, and enforcement cases; and bring key issues to the attention of the Commission for appropriate action. A general description of the ACMUI composition and interactions with NRC will be given. A discussion of the recent activities of the ACMUI and the implication for medical physicists will be presented. Future issues where NRC may have significant impact on the medical physicist will be addressed. Educational Objective: 1. To understand the make-up and responsibilities of the ACMUI and the issues being discussed and their implications on medical physicists.

Making It Safe, Making It Legal, and Creating Peace of Mind

The job of a medical or academic radiation safety officer has three parts: keeping it safe, keeping it legal, and helping people feel that they are safe. Absence of peace-of-mind about radiation protection matters can create very real health effects, even when there is little or no radiation exposure involved. Frightened people may make decisions such as changing jobs (and losing health insurance), terminating a pregnancy, or moving, all of which impact health. Furthermore, frightened people who choose to stick with it may suffer from anxiety, stress, insomnia, and weight loss or even weight gain. Genuinely listening to the concerns of those who benefit from radiation safety services can help to provide peace-of-mind and minimize decisions that are risky to health.

Does abdominal body composition modulate the effects of back belts on the respiratory system?

This study examines the hypothesis that abdominal body composition may modulate the effects that back belts have upon the respiratory function of the wearer. Twelve subjects were divided into two groups based upon abdominal skinfold thickness. Respiratory parameters were compared between groups, between belt-wearing conditions, and between activity levels. Tidal volume ( V T) and respiratory frequency ( f ) were monitored at rest; during a repetitive lifting task; and during recovery from this lifting task. Forced vital capacity (FVC) and forced expiratory volume (FEV 1) were measured during rest and recovery. During exercise, the back belt significantly decreased tidal volume in the high abdominal fat group and increased tidal volume in the low abdominal fat group (Prob> F=0.0002). This study showed no other significant differences in respiratory responses between groups. It is concluded that the abdominal body composition of a given subject can modify the physiological effects of back belts on the respiratory system. It is suggested that abdominal body composition should be controlled for in future studies of the effects of abdominal compression. Relevance to industry Individuals with central obesity and/or preexisting lung disease may experience modifications in lung function that could limit their performance when wearing a back belt. The results of this study, therefore, are relevant to medical practitioners, safety officers, and workers performing manual materials handling tasks.