ECRI warns of gamma cam­era hazard

Modern Healthcare - - NEWS - By Adam Ruben­fire

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.

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