Module 1 L3 pt 2 - Nuclear Medicine Safety and Protocols: Comprehensive Notes

Patient Safety and Consent in Medical Imaging

Do this without parents present at first, especially for younger patients (e.g., around age 12). Acknowledge that parents often want to stay to ask questions, but some situations require the patient to provide information directly.
- You may need to ask about pregnancy or sexual activity if Missy is of childbearing age, not just rely on verbal reports.
- Be aware that pregnancy could be possible even if the patient denies being sexually active, or the pregnancy could be from a family member; verbal reports are not always reliable.
Pregnancy considerations in imaging
- If a patient is of childbearing age, there may be a protocol to perform a pregnancy test in some settings, but it is not always practical in radiography where you may see many patients (e.g., 60–80 per day).
- Decisions about pregnancy testing depend on the exam: tests are more justifiable for abdominal or chest imaging or fluoroscopy where high radiation exposure or direct exposure to the abdominal/pelvic region is involved.
- CT exams with contrast pose significant fetal risk; pregnancy status is an important consideration for contrast use as well as for radiation dose to the fetus.
- Alternatives to X-ray/CT for pregnant patients include ultrasound or MRI when appropriate to avoid radiation exposure.
When to test or verify pregnancy and how to handle imaging decisions
- Test or verify pregnancy status specifically when imaging areas with higher radiation exposure or when radiation would involve the abdomen, pelvis, or chest regions; this includes some CT exams regardless of head imaging with contrast due to contrast-related fetal risks.
- Recognize the role of contrast media in pregnancy risk and discuss alternatives with the ordering physician when appropriate.
Group exercise: preventing wrong-patient x-ray and PSR process
- If an incorrect patient is X-rayed, there is a PSR (Patient Safety Report) to fill out.
- Prevention: verify at least two patient identifiers (e.g., first and last name and date of birth) before imaging.
- Additional verification steps include confirming the exam with the patient (e.g., ask what foot is being imaged for an extremity exam) to ensure alignment with the order and the patient.
- It is common to verify the patient’s identity and the exam order in the room with the door closed to prevent misidentification.
- If an error occurs, you must file a PSR and report the incident to your supervisor; the supervisor typically handles communication with the patient.
- The investigation should cover the who, what, when, where, why, and how, plus corrective actions to prevent recurrence (e.g., reinforce two-identifier checks, order verification, and patient confirmation).
Nuclear medicine (Nuke Med) specifics: misadministration and regulatory thresholds
- Misadministration refers to giving the wrong drug, wrong patient, wrong route, or wrong amount of radiopharmaceutical.
- Criteria to consider:
- Wrong pharmaceutical, wrong patient, wrong route, or wrong amount.
- The wrong amount greater than 10 ext{%} is a key concern and triggers scrutiny.
- If the dose results in $> 50\ \text{rem}$ to any one organ, this may require regulatory reporting and significant follow-up.
- Regulatory reporting expectations (example from MU): NRC reporting within $1\ \text{calendar day}$ of discovery and a written report within $15\ \text{days}$ .
- The consequences can include fines and escalations to federal authorities depending on the error and its impact.
- Dose calculation after a misadministration is necessary to determine actual exposure and inform subsequent actions (e.g., re-testing or re-imaging after clearance).
Value of immobilization, cost, and handling of radiopharmaceuticals
- Radiopharmaceuticals can be very expensive (e.g., some drugs around 20{,}000\ per dose), so wastage and misadministration have larger financial and safety implications.
- When shortages occur (e.g., not enough radiopharmaceuticals for all patients), consider informing the patient, contacting the ordering physician to input new orders, and exploring alternative modalities or rescheduling.
- If late arrival or no-show occurs, attempt to accommodate if possible, but this may result in wastage or delays. In nuclear medicine, rescheduling or adjusting PET/CT protocols may be necessary.
Safety practices across imaging modalities: portable X-ray, nuclear medicine, and radiation safety culture
- Always verify patient identity and the order before imaging.
- Maintain distance from the X-ray source when possible; a common goal is to stay at least $6\ \text{ft}$ away from the tube when feasible.
- Use lead shielding when appropriate, particularly for family members or staff who must be near scattered radiation.
- Wearing lead aprons can reduce exposure by about $80\%\text{ to }90\%$ , but they do not block all radiation; residual exposure remains.
- For high-exposure regions or scenarios where exposure is unavoidable, consider additional protective measures and administrative controls.
- Always use proper collimation and positioning to limit the exposed field to the smallest necessary area.
- Follow the ALARA principle (as low as reasonably achievable) when planning and performing imaging.
Portable X-ray safety: distance, shielding, and dosimetry
- Portable X-ray procedures require careful attention to workflow, minimizing exposure to staff and other patients.
- Key practices include verifying patient identifiers and the order, maximizing distance from the tube, using lead shields, and considering shielding for the patient’s family or staff who cannot leave the room.
- Some facilities require lead wear for personnel who are near the beam; others do not due to practicality. Facility policy determines lead use in portable scenarios.
- The dosimeter (dosimetry badge) is used to monitor exposure; it does not protect you from radiation but records exposure for regulatory and safety purposes.
Collimation and beam geometry: focusing the X-ray beam
- Collimation uses lead plates to narrow the X-ray beam to the area of interest (e.g., arm only).
- The collimator acts like a lens by blocking photons traveling at angles, allowing only photons traveling through the holes to reach the patient and detector.
- A light field is used to visualize where the X-ray beam will go; if the light field and the actual X-ray beam do not align, the unit must be taken out of service.
- Always announce exposures to staff nearby (e.g., “Fire in the hole”) and follow facility protocols.
Equipment checks and dosimetry basics
- Survey meters: key checks before use
- Check the alarm label, ensure the instrument has been inspected, verify the battery, and confirm calibration before use.
- Personal dosimetry devices (badges) and room storage
- Dosimetry badges monitor exposure; they are not kept in the X-ray or CT rooms but stored in a cool, low-background area outside high-radiation zones (the department/hot lab is where isotopes are stored and is highly radioactive and not suitable for badge storage).
- Do not take dosimetry badges home; store them at the department, away from heat and humidity, to avoid drift in readings.
- Badges can be expensive (roughly $10$ \-$15 per badge for staff), so proper use and return are essential to avoid regulatory and financial penalties.
- If there is any doubt about whether a non-patient-facing staff member should wear a badge (e.g., a secretary near a radiology suite), you can place a badge on a wall to monitor exposure over a trial period (e.g., 3\ \text{months} $) to determine if exposure would exceed$ 10\% $of the annual limit; if not, you may discontinue badge use for that role.</li><li>If staff fail to wear badges and are found to exceed exposure limits, NRC regulations could be violated; ensure compliance with proper badge usage.</li></ul></li><li>Spills, spills management, and decontamination in radiopharmacy and imaging<ul><li>Spills require immediate action: warn others, isolate the area, and don protective gear (gloves, goggles, shoe covers) as needed.</li><li>For radioactive spills, cover the spill with absorbent material, then check skin and clothing contamination.</li><li>Survey the area with a survey meter and clean from the outer perimeter toward the center to avoid spreading contamination.</li><li>Dispose of contaminated absorbent material in designated radioactive waste containers.</li><li>If skin contamination occurs, wash with lukewarm water; for more difficult decontamination, consider commercial cleaners (e.g., Radiac Wash or CLR) or abrasive scrub sponges to remove radionuclide deposits.</li><li>In a major emergency, prioritize patient care and call the radiation safety officer and department manager; they coordinate with emergency response teams.</li><li>If cleanup cannot be completed, consider placing lead shielding over the contaminated area as a last-resort measure; note that some isotopes have long physical half-lives, so full decontamination may take time.</li></ul></li><li>Patient safety and exam consent: asking the right questions<ul><li>When obtaining orders and interacting with patients, ask questions to understand why the exam is being performed and ensure the test aligns with the doctor’s orders.</li><li>For MRI, screen for contraindications such as pacemakers or other metal implants or devices.</li><li>Ask about recent imaging to avoid unnecessary repeats and to inform the radiologist about prior results and current symptoms.</li><li>If orders are vague (e.g., dizziness or cough), clarify with the ordering physician because radiology reimbursement depends on a clear clinical indication.</li><li>When orders are carried by clinicians, ensure you understand the clinical rationale to avoid misinterpretation or misadministration; this helps protect patient care and hospital reimbursement.</li></ul></li><li>Clinical anecdotes and risk awareness<ul><li>Repetition of imaging (e.g., multiple CT scans for abdominal pain) should prompt consideration of the probability of a false alarm or non-diagnostic findings; statistics and risk should guide imaging choices.</li><li>Some patients may have fear of imaging or fainting with injections; be prepared for adverse reactions such as vasovagal events, particularly during injections or venous access procedures.</li><li>Always be mindful of radiation dose to patients and the cumulative risk, and balance against clinical necessity.</li></ul></li><li>Lung imaging, contrast reactions, and kidney function assessment<ul><li>Before CT with contrast or other radiopharmaceuticals, assess potential contrast allergies (noting that about$ 5\%$$ of people may have an iodine allergy) and kidney function to prevent nephrotoxicity.
- Do not assume iodine allergy; verify patient history and be prepared for possible reactions; have resuscitation measures ready.
Special considerations for patient mobility and safety
- For upright chest X-rays or mobile imaging where a patient must be standing, assess fall risk and mobility; plan assistance as needed and be prepared for patient fainting or falls.
- Keep a record of patient status during imaging to prevent repeats or injuries.
Historical examples and safety culture in practice
- Real-world incidents (e.g., a radiology team learning from misidentifications or misadministrations) reinforce the need for strict adherence to procedures, transparent reporting, and continuous improvement.
Radiation safety culture and facility-specific practices
- Facilities may implement additional administrative controls to limit radiation exposure: restricting access to high-radiation areas, scheduling workload to distribute exposure evenly, and conducting regular safety training.
- Negative pressure rooms are used in radiopharmaceutical labs to contain airborne radioactive materials; maintain regulatory standards for lung imaging and other procedures that involve inhaled radioisotopes.
- Negative pressure ensures air flows from outside the room into the room, preventing radiological contaminants from escaping to adjacent areas.
Real-world notes on dosimetry and environmental health
- Dosimetry badges measure exposure after the fact and help guide future safety practices; they are not protective devices but essential for compliance and safety.
- Exchange and storage of dosimeters should be managed to prevent heat or humidity damage, which can alter readings; never store badges in hot places or in vehicles during hot weather.
- A cautionary anecdote: a tech stored badges in a basement apartment with high radon exposure, resulting in unusually high monthly readings; this underscores the importance of badge storage in a well-controlled environment, not in personal spaces.
Quick recap: key safety takeaways to memorize for exams
- Always verify two patient identifiers before imaging; confirm the exam with the patient when possible.
- Use ALARA: minimize exposure by distance, shielding, and collimation; aim to keep the exposed field as small as possible.
- Carry out prompt, thorough incident reporting (PSR) for misidentifications and misadministrations; perform a root-cause analysis (Who, What, When, Where, Why, How) and implement preventive actions.
- Understand the regulatory landscape (e.g., NRC reporting timelines) and the consequences of misadministration, including potential fines and required notifications.
- Manage dosimetry responsibly: determine who needs badges based on exposure likelihood; avoid improper badge use; store badges properly; do not take badges home.
- Recognize spill response steps: warn, isolate, protect, absorb, survey, decontaminate, and dispose; involve the radiation safety officer for major incidents.
- Maintain awareness of special considerations in nuclear medicine: high-value radiopharmaceuticals, short half-lives, and the need for careful administration and tracking to prevent misadministration.

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Nuclear Medicine Safety and Protocols: Comprehensive Notes on Patient Identification, Pregnancy, Misadministration, Spills, and Dosimetry