infection . 4 – 6 It is now generally accepted that such activities are best performed centrally within the pharmacy or radiopharmacy department , where appropriate aseptic dispensing facilities are usually found . This was one of the principal recommendations of the Breckenridge report 7 ( and subsequently reinforced for all parenteral medicines by the National Patient Safety Agency in Patient Safety Alert 20 ). 8
Risk of miscalculation or misadministration of dose In a busy clinic , there could be an increased risk of error when carrying out complex calculations , drawing up part of a vial , measuring the correct volumes , etc . This could all add to the pressure on the operator to get the injection done one time , possibly increasing the risks of extravasation as a result .
How can misadministration be avoided ? How should it be dealt with ? It is recommended that the risk of misadministration be managed as follows :
• There should be an independent check of the dose by a second person at the time of drawing up
• The syringe ( in its shielded container ) should be transported to the patient and injected immediately . Therefore drawing up multiple doses in advance is not recommended . Not only does this increase the risk of maladministration , but it will also become a pharmaceutical activity rather than part of the administration process , and , as such , should be supervised by a pharmacist .
Any incident of misadministration involving the wrong patient should be reported both internally via the hospital incident reporting system and externally to the Care and Quality Commission ( CQC ), in accordance with the Ionising Radiation ( Medical Exposure ) Regulations ( IRMER ). 9
Should the right patient receive a dose much greater than that intended , then the need to report to the IRMER coordinator via the CQC website is determined by reference to Regulation 4 ( 5 ) of the IRMER , and will depend on the exposure level and whether it occurred as a result of procedural failure or equipment malfunction . In the case of the latter , the Health and Safety Executive ( HSE ) may need to be involved .
Further advice can be found at the Department of Health website 10 or on the BNMS website ( www . bnms . org . uk ).
How can written IRMER processes help to minimise errors in drawing up ? It is the employer ’ s responsibility to ensure that written IRMER procedures are in place , and their purpose is to control patients ’ exposure to radiation and ensure their safety . 11 They include :
• Correct identification of the individual to be exposed to ionising radiation – this is obviously crucial in minimising risk of maladministration
• Entitlement to act as the IR ( ME ) R roles of referrer , practitioner and operator – so everyone ’ s role and responsibility is defined . Anyone who has a potential impact on the radiation dose the patient receives is considered an operator .
• Processes around medico-legal exposures
• Establishing whether females of childbearing age may be pregnant or breastfeeding
• Quality assurance programmes for equipment and processes
• Assessment of patient dose – again , this is important if maladministration is suspected
• Diagnostic reference levels – these relate to the amount of radiation which may be administered for various tests . Obviously this will feed into the assessment of whether a patient has received an excessive radiation exposure .
• Medical research programmes
• Information and written instructions – this supports a consistently high quality service and helps assure patient safety
• Evaluation for each medical exposure
• What to do in the event of accidental or unintended doses .
What is the significance of the ‘ non-touch ’ aseptic technique and where does this apply ? This is particularly important when drawing up doses in an area that is uncontrolled from a microbiological point of view . The product must remain sterile and therefore steps must be taken to reduce the risk of the operator introducing contamination . Because it is not being performed in a pharmaceutical aseptic area , full aseptic processing , whereby the operator is gowned up and the environment carefully controlled with filtered air , etc , is not possible . As a result , there is a greater chance that the operator will transfer micro-organisms from themselves into the product . It is therefore important that the operator does not touch the rubber septum of the vial , in addition to employing other precautions such as sanitising the area in which the radiopharmaceutical is being manipulated using sterile alcoholic sprays and wipes .
Why is it important to measure the syringe patient dose in a radionuclide calibrator prior to injection ? Because of the radioactive nature of the products , they are constantly decaying . For this reason , the amount of radiation administered is not absolute – it is acceptable to inject an amount that falls within a range , as specified for the test in question .
Different tests will require different amounts of radioactivity to be injected . For example , a bone scan involves waiting for two to three hours while the radio-pharmaceutical is taken up into the skeleton and disperses from the bloodstream . During this time the radiation will be constantly decaying . The agent is also spread throughout the entire skeleton and , for both these reasons , the bone scan will require a larger amount of radiation than a lung scan , for example . In this case , the radioactive tracer is retained in a much smaller area and imaging can take place almost immediately , hence the smaller amount of radiation required .
In order to ensure the patient is to be injected with the correct amount of radioactive tracer for their examination , each dose must be measured before administration using a dose calibrator .
19 HHE 2018 | hospitalhealthcare . com
References 1 UK Radiopharmacy Group on behalf of the BNMS . Safe drawing up of radiopharmaceuticals in nuclear medicine departments . www . bnms . org . uk / images / stories / UKRG / UKRG _ Drawing _ up _ Feb-12 . pdf ( accessed March 2017 ). 2 RQA Multiple Use of Injections . 3 Ionising Radiation Exposure of the UK Population : 2010 . Review by Public Health England . www . phe-protectionservices . org . uk / cms / assets / gfx / content / resource _ 3595csc0e8517b1f . pdf ( accessed March 2017 ). 4 Daily MK , Dickey JB , Packo KH . Endogenous Candida endophthalmitis after intravenous anaesthesia with propofol . Arch Ophthalmol 1991 ; 109:1081 – 4 5 Bennett SN et al . Post operative infections traced to contamination of an intravenous anaesthetic , propofol . N Engl J Med 1995 ; 333:147 – 54 . 6 Kuehnert MJ et al . Staphylococcus aureus bloodstream infections among patients undergoing electroconvulsive therapy traced to breaks in infection control and possible extrinsic contamination by propofol . Anesth Analg 1997 ; 85:420 – 5 . 7 Breckenridge A . The Report of the Working Party on the Addition of Drugs to Intravenous Infusion Fluids ( HC ( 76 ) 9 ). ( The Breckenridge Report ) London . Department of Health and Social Security ; 1976 . 8 National Patient Safety Agency . Patient safety Alert 20 . Promoting safer use of injectable medicines . Ref NPSA / 2007 / 20 . March 2007 . www . npsa . nhs . uk / health / alerts ( accessed March 2017 ). 9 SI 2000 No . 1059 The Ionising Radiation ( Medical Exposure ) Regulations 2000 . London . The Stationery Office ; 2000 . www . legislation . gov . uk / uksi / 2000 / 1059 / contents / made ( accessed March 2017 ). 10 Department of Health . Reporting incidents of radiation . www . dh . gov . uk / en / Publicationsandstatistics / Publications / PublicationsPolicy AndGuidance / DH _ 4007957 . 11 Society of Radiographers . Guidance on IRMER procedures . www . sor . org / learning / document-library / irmer- 2000-and-irme-amendment -regulations-2006 / 1-irmeremployer-s-proceduresschedule-1 ( accessed March 2017 ).