HospitalInspections.org

A. Based on staff interview and record review, the Critical Access Hospital (CAH) failed to ensure patients or personnel were protected from exposure to radiation hazards.

The CAH reported 498 acute inpatients for the most recent annual program evaluation.

This failure has the potential to affect all patients who receive Radiology services and the 7 employees of the Radiology department.

Findings Include:

1. An interview conducted with the Radiology Supervisor on 3-10-2016 at 3:00 P.M. revealed the lead aprons, gloves and shields (lead garments protect the individual from radiation generated during radiological procedures) were tested for defects annually.

2. A review of the records of the testing of these items stated only "Aprons, gloves, shields all ok"
This system did not specify each item individually to ensure all lead lined garments had been checked.

3. This same interview with the Radiology Supervisor confirmed that the current system did not verify the condition of each item, individually and in fact, she did not know how many aprons and other garments were available for use by staff and patients in the CAH and some additional garments were located in surgery .

B. Based on staff interview, manufacturer's instructions for use as compared with documented records reviewed, the Critical Access Hospital (CAH) failed to ensure patients or personnel were protected from unnecessary radiation exposure.

Findings Include:

1. An interview conducted with the Radiology Supervisor on 3-10-2016 at 3:30 P.M. revealed the phantom test was performed once per week on the Computerized Tomography (CT) scanner.

(A phantom is a poly-acrylic devise that approximates the size and density of the human head and torso. When the phantom is subjected to radiation from the CT scanner, it produces predetermined readings to ensure it is functioning properly, prior to subjecting patients to radiation.)

(CT scanner combines a series of x-ray images taken from different angles and uses computer processing to create cross-sectional images, or slices, of the bones, blood vessels and soft tissues of the body.


2. The manufacturer's instructions for use of the CT scanner stated (on page 12-3 of the operations manual,) "GE recommends that you acquire scans of Sections 1,2, and 3 of the QA(Quality Assurance) Phantom each day."
3. The log of phantom performance was reviewed. The phantom test was documented as performed once per week for the time period January, 2016 through March 10, 2016.
4. During this same interview with the Radiology Supervisor she confirmed the phantom was not performed daily, as specified.