SPECIAL - Non-interpretive skills Flashcards
Reactive, retrospective, “policing”; punitive, finger pointing; “who was at fault after a medical error”; old term - QA/QI/QC?
Quality assurance (QA)
Both prospective and retrospective; avoids assigning blame; goal is to create systems that prevent medical errors; continuous process - QA/QI/QC?
Quality improvement (QI)
System for maintaining a pre-determined level of quality; planning, inspection, corrective action if required - QA/QI/QC?
Quality control (QC)
Six improvement aims for the healthcare system
from IOM; safety, timeliness, effectiveness, efficiency, equity, patient-centeredness (“STEEEP”)
Quality care is…
coordinated, compassionate, innovative
Six core competencies of MOC
medical knowledge, interpersonal/communication skills, patient care, professionalism, practice-based learning/improvement, systems-based practice (“MIPPPS”)
Best practices (2)
dashboards, benchmarking
Measurement of the quality of an organization’s policies, products, programs, and strategy
benchmarking; helps determine improvements, achieve high performance, and improve performance
Visual display of the most important information needed
dashboard
PDSA (acronym)
Plan-Do-Study-Act
PDSA steps
plan = develop hypothesis, do = test hypothesis, study = analyze data, act = draw conclusions and determine next steps
Developing a hypothesis (P, D, S, or A?)
Plan
Testing the hypothesis (P, D, S, or A?)
Do
Analyze the data (P, D, S, or A?)
Study
Draw actionable conclusions and determine next steps (P, D, S, or A?)
Act
Improvement is most effective when… (PDSA)
multiple PDSA cycles are run in parallel or in rapid succession
Major quality improvement methodologies
PDSA, Lean Process Improvement, and Six Sigma
When and who published “To Err Is Human”?
IOM, 1999; part of Quality of Health Care in America project
Number of deaths attributable to medical error per year
44,000 to 98,000
Percentage of hospitalizations in which adverse events occur
3-4%
Percentage of adverse events leading to death
7-14%
Failure of a planned action to be completed as intended or use of a wrong plan to achieve an aim
medical error; highest risk locations are ER, OR, and ICU
Parent organization of Institute of Medicine
National Academy of Sciences (NAS)
Most medical errors were system errors or individual errors?
system errors
Factors contributing to medical errors (from IOM report) (4)
decentralized nature of healthcare, failure to focus on errors, impediment to identify errors, failure of third-parties to incentivize improving safety
Organization funded by congress in response to IOM report
Agency for Healthcare Research and Quality (AHRQ); created in 2000
Purpose of “Never Events” list
to serve as a basis of a mandatory reporting system
Discipline which examines how systems work in actual practice with real human beings
human factors engineering; attempts to design systems that optimize and minimize risk of error
Standardization of equipment and processes is an axiom of…
human factors engineering
Checklists are an example of ________
standardization
Organizations that consistently minimize adverse events despite carrying out instrinsically complex and hazardous work
high reliability organization (HRO)
Characteristics of a HRO
fixation on failure, avoidance of oversimplification, respect of expertise, dedication to resilience, sensitivity to operations (“FARDS”)
Features of a safety culture
acknowledgement of high risk nature of activities, blame-free environment, encouragement of collaboration, commitment of resources to address safety concerns
Authority gradients encourage or undermine safety culture
undermine
Measurement of Safety Culture
surveys of providers at all levels
Examples of Safety Culture surveys
Patient Safety Culture Survey and Safety Attitudes Questionnaire (both from AHRQ)
Teamwork systems, administrative walk-arounds, and unit-based systems are associated with improvements in….
Safety Culture
Model with focus on addressing systems issues that lead individuals to engage in unsafe behaviors, while maintaining individual accountability
Just Culture model
Three manageable behaviors of the Just Culture model
Human Errors, At-risk Behaviors, Reckless Behaviors
In a Just Culture model, the response to an error is predicated on the severity of the event or the type of behavior associated with the event
type of behavior associated with the adverse event; e.g. refusing to do a timeout even if no patient was harmed would result in punitive action
Response to Human Errors (e.g. slips)
Human Errors are consoled
Response to At-risk Behaviors (e.g. shortcuts)
At-risk Behaviors are coached
Response to Reckless Behaviors (e.g. ignoring required safety steps)
Reckless Behaviors are punished
Human Reliability Curve relates…
Human reliability (y-axis) to factor affecting human performance (x-axis); never reaches 100% reliability
Area under Human Reliability Curve
Successful operation (by the human)
Area above Human Reliability Curve
Human error
Person in an organization who takes ownership of processes and foster creation/maintence of the safety culture
safety coach/champion
Primary focus in a safety-report system
the patient, the system, and the event
Healthcare worker who is traumatized by or unduly punished for an error or adverse patient event
second victim; may exhibit signs similar to PTSD
Two broad categories of radiologist errors + which is more common
perceptual errors and cognitive/interpretive errors
Most radiologist errors are cognitive or perceptual?
perceptual (60-80%)
Poor lesion conspicuity, reader fatigue, rapid pace of interpretation, phone calls, and satisfaction of search are examples of which type of radiologist error?
perceptual errors (missed finding which is present in retrospect)
Error analysis tool used to examine serious adverse events
root cause analysis; identifies underlying problem that increases likelihood of errors; avoids focusing on individal mistakes; goal is to eliminate latent errors
Error occurring at the interface between humans and a complex system (in RCA)
active errors (how event occurred)
Hidden problems in healthcare systems that contribute to adverse events (in RCA)
latent errors (why event occurred)
“Quick fix” in root cause analysis
a quick fix may be implemented early in the RCA process to rapidly reduce the risk of a similar error, even though it may not be the definitive solution to a root cause
Accuracy vs. precision - how variable is a test result in ANY given situation?
precision
Accuracy vs. precision - how variably does the test result reflect the desired diagnosis?
accuracy; (TP + TN) / (TP + FN + FP + TN)
Patient identifiers, patient assessment, informed consent, and medication reconcilation are part of what process?
peri-procedural care
Number of patient identifiers that should be used before a procedure
2 or more; include patient name, MRN, phone number, DOB, photo ID, last 4 SSN
Example of a piece of information that cannot be used as a patient identifier
patient location or room number
Which is not an acceptable source of patient identifiers; the patient, a relative, a guardian, a domestic partner, or a healthcare provider who has previously identified the patient?
all are acceptable sources of patient identifiers
Elements of informed consent (5)
discussion of procedure, benefits, potential risks, reasonable alternatives, risk of refusing procedure
Six rights of medication administration
right patient, right medication, right route, right dose, right time, and right documentation
Pre-procedure verification, procedure site marking, and performing a timeout are components of what?
Universal Protocol
Items which must be agreed on during a timeout
correct patient identity, correct site, procedure to be performed; completion of the timeout must be documented
Maximum sterile barrier technique
for more invasive procedures (e.g. central line); defined by National Quality Measures Clearinghouse; cap, mask, sterile gown, sterile gloves, large sterile sheet, hand hygeine, cutaneous sepsis
Which organizations collaborated on the ‘Practice Parameter for Sedation/Analgesia’?
ACR and SIR (Society of Interventional Radiology)
Levels of sedation are defined by whom?
Joint Commission and American Society of Anesthesiologists (ASA)
Levels of sedation (4)
minimal (anxiolysis), moderate, deep, and general anesthesia
Moderate sedation description
patient retains ability to maintain a patent airway and can be aroused by physical/verbal stimulations
ASA class(es) of patients that qualify for moderation sedation
class I (normal healthy patient), class II (mild systemic disease); classes III and IV may require additional consideration for sedation
Discharge criteria after use of a sedation reversal agent
patient’s level of consciousness and vital signs should return to an acceptable level for at least 2 hours prior to discharge
Who was/is responsible for developing/updating the ACR Guidance Document for Safe MR Practices?
Blue Ribbon Panel on MR Safety (which was established by the ACR)
Publically accessible, unrestricted MR zone
zone 1
MR zone for greeting patients, obtaining histories, and screening patient
zone 2; under supervision of MR personnel
Restricted access MR zone(s)
zones 3 and 4
MR zone with physical restriction from entry (door, lock, etc.)
zone 3
MR zone containing the MR magnet
zone 4
First action in the event of a quench
evacuate the room immediately
First action in the event CPR is required (or other medical emergency)
remove patient to a magnetically safe location
Type of gas that fills MR magnet room in a quench
helium gas (displaces oxygen); same process occurs if a tank bursts or there is a helium leak; oxygen levels in the scanner room must be monitored at all times
When must oxygen levels in the MR scanner room be monitored?
at all times
Potentional MR complication of loops of wire, metallic transdermal patches, and large tattoos
skin burns; first two should be removed prior to entry, ice pack may need to be applied to area of tattoo during scanning
T/F - the majority of contrast reactions are mild and self-limited
true
Overall incidence of contrast reactions with low osmolality media
0.2-0.7% (or <1%)
Three goals for contrast administration
appropriate for patient and indication, minimize likelihood of contrast reaction, and be prepared to treat a reaction
Greatest risk factor for a contrast reaction
history of prior reaction to contrast; assoc. with 5x increased risk
Increased risk of contrast reaction with history of shellfish allergy?
no
Risk factors for a contrast reaction
history of prior reaction to contrast > history of allergic reaction not related to contrast (atopy, asthma, major anaphylactic reaction), significant cardiac disease
Who gets premedication for contrast?
patients at increased risk for an acute contrast reaction
Most contrast reactions are due to histamine release or IgE-mediated?
histamine release (90%)
Preferred premedication regimen - PO or IV?
PO; risk of reaction to corticosteroids when administered IV
Increased contrast osmolality is associated with increased or decreased likelihood of a contrast reaction?
hyperosmolar contrast is assoc. with increased likelihood
PO premedication regimens for contrast reaction (2)
50mg prednisone PO at 13, 7, and 1 hour before injection + diphenhydramine 1 hour before; or, 32mg methylprednisolone PO at 12 and 2 hours before + diphenhydramine 1 hour before
IV predmedication regimen for contrast reaction (in patients unable to take PO)
same as prednisone protocol, but with 200mg IV hydrocortisone and IV/IM benedryl
Most desirable contrast premedication protocol when scan is desired in less than 4-6 hours
40mg methylprenisolone or 200mg hydrocortisone IV q4 hours until contrast is required + 50mg diphenhydramine IV at 1 hour before
Premedication has a proven benefit in reducing major or minor contrast reactions, or both?
minor contrast reactions; no proof for protection against severe life-threatening reactions
IV contrast utilization in patients with thyroid cancer or hyperthyroidism
IV contrast should be avoided 4-6 weeks prior to anticipated I-131 treatment (may “block” thyroid uptake of I-131)
Contraindications to premedication with steroids
diabetes, uncontrolled HTN, TB, systemic fungal infection, PUD, diverticulitis
Types of contrast reactions (3)
mild, moderate, severe; may be considered allergic-like or physiologic
Type of contrast reaction: hypertensive urgency
moderate, physiologic; if hypertensive emergency, then severe
Type of contrast reaction: vasovagal reaction that requires treatment
moderate, physiologic; if treatment is not required, then mild
Type of contrast reaction: diffuse urticaria
moderate, allergic-like; if focal urticaria, then mild
Examples of severe contrast reactions
anything that causes dyspnea/stridor, hypoxia, or hypotension; also arrhythmia, seizure, hypertensive emergency
Dilution for IM epinephrine
1:1,000; ‘M’ in IM for ‘mill-‘ (1/1000th)
Dilution for IV epinephrine
1:10,000 via slow infusion; IV administration of epinephrine is preferred in severe cases
Initial step for managing a contrast reaction
monitor vitals/pulse ox/preserve IV access +/- oxygen at 6-10 L/min via face mask
Dose limit for epinephrine administration (contrast reaction)
repeat doses may be given up to a total of 1 mg; for IM, 0.1 mL = 0.1 mg (1 mL total); for IV, 1 mL = 0.1 mg (10 mL total)
Dose limit for atropine administration (contrast reaction)
repeat doses may be given up to a total of 3 mg; typical single dose is 0.6 to 1.0 mg IV
Hives management flow chart (contrast reaction)
usually no treatment; if symptomatic => benadryl; if severe => epi
Hypotension (SBP <90 mmHg) management flow chart (contrast reaction)
O2 + elevate legs => rapid IVF => if bradycardic give atropine OR if tachycardic give epi => 911
Bronchospasm management flow chart (contrast reaction)
O2 => inhaled albuterol => epi => 911
Laryngeal edema management flow chart (contrast reaction)
O2 => epi => 911
Hypertensive crisis (SBP >200 mmHg) management flow chart (contrast reaction)
O2 => IV labetalol (or SL nitroglycerin) => IV lasix => 911
Pulmonary edema management flow chart (contrast reaction)
O2 + elevate head => IV lasix => morphine => 911
Seizure management flow chart (contrast reaction)
O2 => lorazepam => 911
Hypoglycemia management flow chart (contrast reaction)
O2 => PO glucose (or D50W or IM glucagon) => 911
Unresponse/pulseless management flow chart (contrast reaction)
911 => CPR + defibrillate + epi
By definition, post-contrast AKI (PC-AKI) occurs within _______ hours of contrast administration
48 hours; CIN is subset of PC-AKI where the kidney injury is determined to be due to intravascular contrast
Arterial or venous administration of contrast material is associated with a greater risk of CIN?
arterial
Typical clinical course of CIN
rise in Cr within 24 hours => peaks at 4 days => returns to baseline within 7-10 days
Permanent renal dysfunction related to CIN is rare or common?
rare
Two main risk factors for developing CIN for which there is consensus
pre-existing renal insufficiency and AKI
Most proven strategy for prevention of CIN in at risk patients
IV hydration with 0.9NS or LR; 100 mL/hour for 6-12 hours before and 4-12 hours after
Risk of CIN in patients with anuric end-stage renal disease
no risk of CIN; thus no need for urgent dialysis after IV contrast
Patients whom the ACR recommends obtaining a serum Cr prior to contrast administration
age >60, h/o renal disease, hypertension, diabetes, or use of metformin; if patient is stable, Cr value within 30 days is acceptable; same criteria are used for obtaining a GFR prior to gad administration (minus metformin)
Low or high osmolality contrast agents are preferred in patients with renal insufficiency?
low osmolality contrast (less nephrotoxic); high osmolality contrast is not currently used in US
Majority of gadolinium-based contrast reactions are mild or severe?
mild; e.g. nausea/vomiting, itching, warmth, paresthesias; allergic-like and anaphylactic reactions are rare
Risk factors for gadolinium-based contrast media (4)
prior reaction to GBCM (8x), allergy to iodinated contrast, asthma, other non-contrast-related allergies
Pathway of GBCM in maternal-fetal circulation
maternal circulation => cross placenta => fetal circulation => filtered by fetal kidneys => excreted into amniotic fluid => stays for prolonged time and may dissociate from chelate
Gad is an absolute or relative contraindication in pregnancy
relative contraindication
Risk factors for developing NSF (2)
AKI or severe CKD (1-7% risk in stage 4/5 CKD)
GFR threshold above which no special precautions for gad are required
GFR >40
Patients in whom GBCM administration should be avoided or severely limited
dialysis patient, GFR <30, or AKI
Effect of flow rate on contrast extravasation
higher flow rate (power injection) assoc. with increased severity of the extravasation, but NOT increased frequency
Risk factors for contrast extravasation related to venous access (3)
distal access sites (hand/wrist/foot/ankle), line older than 24 hours, multiple punctures into same vein
Major risk factors for development of compartment syndrome following contrast extravasation (2)
volume of extravasated contrast, capacity of site of extravasation
Severe complications of contrast extravasation
compartment syndrome, skin ulceration/tissue necrosis
Indications for surgical consultation after contrast extravasation
progressive pain/swelling, decreased capillary refill, sensory changes, skin ulceration/blistering
Three fundamental principles of medical professionalism
primacy of patient welfare (serve the interest of the patient; altruism), patient autonomy, social justice
Fair distribution of healthcare resources and elimination of discrimination refers to what principle?
social justice
First 5 “commitments” of the Physician Charter on Medical Professionalism
Professional competence, Honesty with patients, Patient confidentiality, Maintain appropriate patient relations, Improving QOC
Second 5 “commitments” of the Physician Charter on Medical Professionalism
Improving access to care, Just distribution of finite resources, Scientific knowledge, Maintaining trust by managing conflicts of interest, Professional responsibilities
PHI (acronym)
protected health information; information which identifies patient or could be used to reasonably identify patient
Situations in which PHI can be transmitted without individual authorization (5)
at individual’s request; in the course of treatment; for payment; for operations involving quality/compliance/fraud; when required by law
Standard communication in radiology refers to what?
creation and delivery of written reports
Medically significant changes to a preliminary report should be…
communicated directly to the referring physician; not required for minor changes
When viewed in an electronic system an addendum should appear before or after the original report?
before; a final report cannot be edited, can only be addended
Level of non-standard communications: new or unexpected findings that are life threatening or require an immediate change in management
level 1; requires direct contact between radiologist and referring physician (or other responsible provider); communication must be documented
Definition of a ‘critical result’
any result or finding that may be considered life threatening or that could result in severe morbidity and require urgent or emergent clinical attention
Accredited facilities are required to define critical tests and critcal results, and monitor reporting of those results by whom?
Joint Commission
Time requirement for level 1 communication
within 30-60 minutes of time the observation is made
Relationship between critical results and level 1 communication
all critical results require level 1 communication, but not all level 1 communication is a critical result
Do critical tests require rapid communication?
yes, regardless of what the study shows; e.g. negative PE study
Level of non-standard communications: new or unexpected findings that could result in mortality or significant morbidity if not treated urgently (within 2-3 days)
level 2; call service or an associate may be used to communicate results
Time requirement for level 2 communication
within 6-12 hours
Level of non-standard communications: new or unexpected findings that could result in significant morbidity if not treated appropriately, but are not immediately life-threatening
level 3; these findings are often communicated electronically
Time requirement for level 3 communication
not time sensitive
Documentation for non-standard communications requirements
date and time of communication, name of person reporting findings, name of person receiving findings, +/- time observation was made (for level 1 findings)
“Curbside consults” and “wet reads” are examples of what?
informal communications; should still be documented in some form by radiologist
Percentage of abnormal radiographic findings that are missed
30%
Most common cause of malpractice suits against radiologists
errors in diagnosis; further categorized as failure in detection, interpretation, communication of results, or suggesting appropriate follow-up test
Radiologist diagnostic errors can be classified as… (2)
cognitive errors (e.g. missed findings) or systemic errors (e.g. failure of communication)
Meaning of ‘radiologic errors’
combination of cognitive and systemic errors; e.g. missed findings due to long shift length
Body designated to review and monitor research involving human subjects
IRB; required to register with DHHS
Requirement for all human subjects participatring in a research study
must give informed consent
CPT code (acronym)
current procedural terminology
What body maintains CPT codes?
American Medical Association (AMA)
ICD (acronym)
international classification of disease; formulated during a conference sponsored by WHO
Concordance between CPT and ICD codes is termed what?
medical necessity
Combining individual components of a complicated procedure for billing purposes is called what?
bundling
RVU (acronym)
relative value unit
What is meant by ‘meaningful use’?
basically using EMR technology to improve outcomes, communication, transparency, and efficiency
Type of data: data values fall in categories without any inherent order
nominal; e.g. race, gender, subspecialty
Type of data: data possess some inherent order but the size of the interval between categories is not quantifiable
ordinal; e.g. BI-RADS, assigning excellent/very good/good/fair ratings
Type of data: data possess inherent order and the interval between successive values is equal
interval; can be averaged; may be continuous or discrete; e.g. temperature in celsius (continuous) or number of seizures per month (ordered discrete)
Type of data: similar to interval data, but measures reflect a ratio between a continuous quantity and a unit magnitude of the same kind
ratio; e.g. birth weight in kg, percent vessel stenosis
Type of variable: basic units are not quantifiable
categorical; may be nominal or ordinal; e.g. race, gender
Type of variable: can take values within a given interval and generally have higher information content
continuous or ordered discrete; e.g. time, age, blood pressure
Which measurement is more affected by outliers - mean or median?
mean
Mode is most often used for these variable types
categorical or nominal; e.g. race, gender
Amount of spread around the mean of data set
variance
Average distance of observations from the mean
standard deviation; std dev = sqrt(variance)
Meaning of n-th percentile
value at which n percent of the data lie below
Type I error
reject the null hypothesis when the null is true = FALSE POSITIVE; α is the probability of type I error
Type II error
fail to reject the null hypothesis when the null is false = FALSE NEGATIVE; β is the probability of type II error
Meaning of p-value
probability that the observed effect was merely chance
p-value greater than alpha
non-signficant result; does not prove null hypothesis, but cannot eliminate it
p-value less than alpha
statistically significant result
Range of reasonable values intended to contain the parameter of interest
confidence interval; desired degree of confidence is most often 95%
Relationship between CI and precision of an estimate
wide CI = less precise; narrow CI = more precise
Sensitivity (definition)
proportion with disease who test positive; TP/(TP+FN)
Specificity (definition)
proportion with no disease who test negative; TN/(TN+FP)
SNOUT mnemonic
high SeNsitivity test to rule OUT the disease; negative result suggests a low chance of having disease
SPIN mnemonic
high SPecificity test to rule IN disease; positive result suggests a high chance of having disease
Power
power = 1 - β, where β is the probability of making a type II error
Tests with high ________ have low type I error rates
high specificity; α = 1 - specificity
Tests with high ________ have low type II error rates
high sensitivity; β = 1 - sensitivity
Good screening tests have high _________
high sensitivity
Good confirmatory tests have high _________
high specificity
Studies used to estimate PPV and NPV should include what?
prevalence of disease in the study population; PPV and NPV are influenced by prevalence
What should be done if prevalence of disease in the study population does not match the prevalence in the general population?
likelihood ratios should be used instead of PPV and NPV; e.g. case control studies do not yield prevalence and thus cannot be used to estimate PPV and NPV
ROC (acronym) - as in ROC curve
receiver operating characteristic
ROC curve axes
x-axis = false positive rate (or 1 - specificity); y-axis = true positive rate (or sensitivity)
How is an ROC curve generated?
plotting sensitivity and specificity values for each “cut-point” along the curve
What does area under the ROC represent?
test accuracy; see http://gim.unmc.edu/dxtests/roccomp.jpg
Bias: when comparisons are made between subjects that differ in ways not being studied
selection bias; may reduce generalizability of study results to broader population
Bias: important subgroups are missing from the sample
spectrum bias (type of selection bias)
Bias: patients with positive or negative test are preferentially referred for the gold standard test
verification or referral bias (type of selection bias); sensitivity and specificity are based only on those who underwent the gold standard test
Bias: members of a population are more or less likely to be included than others
sampling bias (type of selection bias)
Bias: study groups are measured differently
measurement bias
Bias: tests performed or interpreted without blinding
review bias (type of measurement bias)
Bias: two factors are associated and the effect of one is distorted by the effect of the other
confounding bias
Bias: study volunteers tend to be healthy and have better outcomes
screening/compliance bias
Bias: period of time between detection via screening and when detection would have occurred due to symptoms
lead-time bias; patients appear to live longer because they’re detected earlier, but still die at the same time (earlier treatment is no more effective)
What should you compare to avoid lead-time bias?
age-specific mortality rates
Bias: screening tends to find slow-growing tumors, which inherently have a better prognosis
length-time bias; this is because fast-growing tumors are more likely to be symptomatic and present outside of screening
Bias: screening detects disease that will never become clinically important in a patient’s lifetime
overdiagnosis
