There’s a significant risk of complication when IV contrast medium is administered to patients during imaging procedures—commonly resulting from a breakdown in prescribing, administration, communication, or a failure to follow established procedures.
One of the most serious consequences that can result from an IV contrast error is acute kidney injury (AKI), exhibited by a worsening of renal function. An AKI typically occurs within 48 hours of receiving IV contrast, and manifests as contrast-induced nephropathy (CIN) as a result of IV administered iodinated contrast medium.
This study reviews how a communication breakdown and a failure to adhere to recommended procedures adversely affected the care of one patient. We’ll also provide risk-management strategies for documenting communication between the ordering provider and radiologist to help avoid similar situations.
Under advisement from her primary care physician, the patient presented to the hospital with elevated liver enzymes, questionable Tylenol toxicity, alcoholism, and dehydration. The on-call ED physician suspected she could be suffering from alcoholic hepatitis or Budd-Chiari syndrome, and so she was admitted for rehydration and further studies.
The ED physician ordered an ultrasound study of the biliary tract during her hospitalization to evaluate for possible gallstones and pancreatitis, and the radiologist caring for the patient also identified significant fatty infiltration of the liver. Given the patient’s clinical history and the poor visualization of the right hepatic vein, the radiologist concluded that he could not rule out Budd-Chiari syndrome. He indicated to the ultrasound technologist that there was an area on the ultrasound that concerned him.
Conflicting accounts from the technologist and the radiologist made it unclear whether or not the radiologist requested a CT of the abdomen for further evaluation. According to the radiologist, he wanted to speak with the primary care physician before proceeding with a CT scan, yet the ultrasound technologist claimed that he was asked to take the patient for further imaging studies.
The ultrasound technologist transported the patient to CT in a wheelchair and told the CT technologist that the radiologist had ordered the scan. The technologist proceeded with administering contrast and performing the CT scan without a written order, and the patient’s lab values were not checked before administration of contrast.
Following the procedure, the patient’s creatinine level rose to 7.5 from 3.4 on admission to hospital. The patient developed acute renal failure from intravenous contrast, which required hemodialysis. Due to the patient’s worsening status, she was transferred to a tertiary care center for further management. After several days of hemodialysis, her renal complications resolved. This case was settled before reaching the trial phase.
What Went Wrong?
There were a few breakdowns in communications during this process. The radiologist failed to document his conversation with the ordering physician regarding a recommendation for a CT examination. He also didn’t directly inform the CT technologist to complete the study. Furthermore, after receiving direction from the ultrasound technologist, the CT technologist failed to verify a written order before proceeding with the test.
The hospital also didn’t have a protocol in place that required patient labs to be completed before administering contrast. Obtaining the patient’s Blood Urea Nitrogen (BUN) and creatinine levels prior to contrast administration could have altered the course of treatment in such a way that would prevent kidney failure.
Risk Management Takeaways
- Hospitals and practices should require all radiology staff and providers to document patient care communications in the medical record, including information provided, advice given, and study findings. This documentation should include the date and time of the communication, name of person called, and the person who made the call.
- Technologists should confirm that imaging study orders include a written request with the provider’s signature.
- Hospitals and practices should implement a written protocol for administration of IV contrast, including a checklist for the patient to complete regarding the following risk factors:
- Previous adverse reactions
- Renal history (e.g., dialysis, kidney transplant, single kidney renal cancer, renal surgery)
- Diabetes mellitus history
- Use of Metformin or Metformin-containing drug combinations
- Any lab tests ordered
- Any patient allergies
- Providers should ensure that a baseline serum creatinine (with or without eGFR) is available or obtained before the injection of contrast medium in any patient considered at risk for CIN (see the ACR Manual on Contrast Media).
- If a patient’s serum creatinine level is elevated, the radiologist should document clearance to proceed with CT scan.
- When necessary, radiologists should consult with the primary care/attending physician to determine the benefit versus risk of performing study with contrast.
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Details on a radiologist’s failure to effectively communicate his interpretation of findings and guidance for how to avoid a similar outcome.