Performing x-rays using iodine dye increases risk for kidney failure

Performing x-rays using iodine dye places patients with impaired kidney function at increased risk for kidney failure. Known as Contrast-Induced Nephropathy (ne-FROPP-a- thee) or ''CIN,'' this complication is the third most common cause of hospital-acquired kidney failure in the United States and Europe, accounting for 10-12 percent of all such cases.

Since June 2004, the Pennsylvania Patient Safety Reporting System (PA- PSRS) has received more than 70 reports showing the negative effects the iodine dye has on patients' kidneys when administered. Patients who develop CIN have more complications, a worse prognosis, more serious long-term outcomes and prolonged hospital stays which result in increased medical costs. While less than 2 percent of patients who develop CIN require dialysis, 30 percent of these patients experience chronic kidney problems.

The Patient Safety Authority has issued a Supplementary Patient Safety Advisory along with its quarterly 2007 March Patient Safety Advisory to raise awareness of the complication which cannot be reversed, but may be prevented. A toolkit containing CIN information for facilities to raise awareness of the complication accompanies the Supplementary Advisory. The toolkit contains: a presentation with CIN information for educating clinicians; an algorithm to help providers recognize patients with risk factors for CIN; and a poster containing the pertinent CIN information to raise awareness in facilities.

''The Authority does not normally release two Advisories at the same time, but given the number of patients who could be affected by CIN we felt it warranted a separate issue,'' said Dr. John Clarke, clinical director of PA- PSRS. ''Raising awareness of the issue is important for preventing the complication which can alter a person's life tremendously. Identifying patients who are high-risk through lab tests and other screening procedures is the first important step to prevention.''

More about the risk reduction strategies for CIN can be found in the Supplementary Advisory article, ''Contrast-Induced Nephropathy: Can This Iatrogenic Complication of Iodinated Contrast be Prevented?'' at http://www.psa.state.pa.us/psa/lib/psa/advisories/vol1no4_supplementary_march_ 2007/v4_s1_suppl_advisory_mar_30_2007.pdf.

The Authority's quarterly 2007 March Patient Safety Advisory contains more articles developed from real events that have occurred in Pennsylvania's healthcare facilities. The articles also provide advice and prevention strategies for facilities to implement within their own institutions. Highlights of these articles include:

• Airway Fires during Surgery: Airway surgeries that involve ignition sources to cut tissue or coagulate blood vessels (e.g., electrosurgical units, lasers) pose a significant and sometimes deadly risk of fire in an oxygen-rich environment. The Advisory provides guidance on preventing potentially catastrophic airway fires and on fighting these fires when they occur.
• Commonly Used Drug, Serious Risks: The drug Promethazine commonly used by physicians for patients suffering from nausea and allergies can have serious consequences if administered intravenously. Patients have experienced gangrene and other serious effects of inadvertent IV administration.
• Product Recall: Reports have been received describing stopped infusion pumps of the Baxter Colleague series. The cause of the interruptions was not clear in most reports to PA-PSRS, although several discussed failures due to battery-related conditions, and the company has issued product recalls for similar conditions. Reports to PA-PSRS suggest that efforts to address problems with the Colleague series pumps may not have reached all clinical settings or facilities.
• Complications with Nerve Blocks During Eye Surgery: Occasionally, patients undergoing eye surgery in Pennsylvania who received a retrobulbar block to numb the eye area have experienced cardiac arrest and other injury as a result of the drug. Although topical anesthetics are now frequently used instead of the once popular retrobulbar block, it remains important to use modern techniques to minimize complications. The modern techniques are described.

For a copy of the 2007 March Patient Safety Advisory click here.

The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (''Mcare'') Act as amended, to help reduce and eliminate medical errors by identifying problems and recommending solutions that promote patient safety. Under the Act, all Pennsylvania-licensed hospitals, birthing centers, ambulatory surgical facilities and certain abortion facilities are required to report what the Act defines as ''Serious Events'' and ''Incidents'' to the Authority. More than 475 healthcare facilities are subject to Act 13 reporting requirements.

Facilities submit reports of Serious Events and Incidents through the Pennsylvania Patient Safety Reporting System (PA-PSRS), a confidential web- based system that was developed for the Authority under a contract with ECRI, a Pennsylvania-based independent, non-profit health services research agency, in partnership with EDS, a leading international, information technology firm, and the Institute for Safe Medication Practices (ISMP), also a Pennsylvania- based, non-profit health research organization.

More than 485,000 reports have been submitted through PA-PSRS since the program was initiated in June 2004. Ninety-six percent of these reports are Incidents or ''near-misses." Based on those reports, the Authority issues quarterly and supplementary Patient Safety Advisories to advise hospitals and other healthcare facilities about steps they can take to reduce and prevent patient harm.

The Authority has been named a recipient of the 2006 John M. Eisenberg Award for advancing patient safety and quality. Presented jointly by the Joint Commission and the National Quality Forum, the award acknowledges the Authority's impact on patient safety because of efforts to make the PA-PSRS system into a nationally recognized resource for education and learning about patient safety.