ECRI warns of gamma camera hazard
At least five patients and hospital staffers have been injured in the past year because of malfunctions in gamma camera imaging devices, according to the ECRI Institute. Gamma cameras are found in most U.S. hospitals.
There was one well-publicized report in 2013 of a patient at the James J. Peters VA Medical Center in New York City who was crushed to death when the gamma camera apparatus collapsed.
There have been 40 manufacturer recalls of gamma cameras since that year, said Jason Launders, director of operations for ECRI’s health devices group. General Electric Co., Siemens and Royal Philips manufacture gamma camera imaging devices.
The malfunctions were often caused by mechanical problems and sensor failures in the heavy moving compo- nents of the cameras, according to ECRI, a not-for-profit organization that researches patient safety, quality and cost-effectiveness of care. The group said such incidents can be prevented by regular camera maintenance, prompt response to recalls and attentive technologists.
In regard to the 2013 fatality, which involved a General Electric Healthcare-made device, the company “completed full and detailed inspections for all relevant systems; all service related to the recall has been completed, and systems are in use today around the globe,” according to a GE spokesman.
ECRI included the gamma camera in its new list of the Top 10 Health Technology Hazards for 2016.
ECRI’s voluntary database showed an increase in the number of injury reports related to gamma cameras from zero last year to five in the past 12 months, including four in a single month. While that number may seem small, ECRI suspects there may be more near-misses, which often aren’t reported because no serious injury occurred, Launders said.
Gamma camera scans can be used for cardiac stress tests, brain imaging, bone scans and a number of other procedures. During an imaging procedure, two large, heavy box-like structures move around the patient to perform the scan. This movement, which is computer-controlled, positions the imaging device very close to the patient.
The imaging devices have sensors designed to prevent the gamma camera from getting too close. But those sensors have malfunctioned in a number of cases, Launders said.
“It’s like positioning a grand piano with sub-millimeter accuracy within half of an inch of a patient,” he said.
For patient safety, Launders said, it’s important for hospitals to make sure the imaging technologist is present for the full duration of a gamma camera imaging device study, which can take several hours. Prompt imaging technologist action has prevented serious injuries in a number of cases, according to ECRI.
Several incidents reported to ECRI occurred after a hospital failed to adequately respond to a manufacturer recall, Launders said. Hospitals need to immediately respond to such notices, in addition to conducting regular maintenance and inspections of gamma camera equipment.
“We want to make sure that this is something that the C-suite is aware of and puts processes and procedures in place so that it never happens,” Launders said.
Gamma camera studies often take hours
and can lead to injuries.