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An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
An Overview of PET, MRI and PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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An Overview of Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
An Overview of Fibroids | Uterine Artery Embolization The Good, The Bad, The Ugly
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Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
Q&A- Success, Case Add-Ons | Innovation and Application of Real Time Nursing Dashboards
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Ablative Radioembolization | Interventional Oncology
Ablative Radioembolization | Interventional Oncology
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PET/MRI Case Study #3 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI Case Study #3 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Education Strategies to Reduce Human Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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The Anatomy of Errors in Health Care | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
The Anatomy of Errors in Health Care | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
Dashboard Component- Nursing Case Volume per Hour | Innovation and Application of Real Time Nursing Dashboards
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Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Patient Education PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Human Factors Engineering- What is it? | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Human Factors Engineering- What is it? | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Staff Requirements & Education | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
Benefits of UFE | Uterine Artery Embolization The Good, The Bad, The Ugly
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MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
MRI Safety & Screening | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Key Patient Safety Influencers | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Key Patient Safety Influencers | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Clinical Workflow for PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Fibroid or Cancer | Uterine Artery Embolization The Good, The Bad, The Ugly
Fibroid or Cancer | Uterine Artery Embolization The Good, The Bad, The Ugly
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Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
Non-Invasive Ventilation | Respiratory Compromise: Use of Capnography During Procedural Sedation
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Human Factors That Reduce Situational Awareness | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Human Factors That Reduce Situational Awareness | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI vs PET/CT | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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What's Next | AVIR CLI Panel
What's Next | AVIR CLI Panel
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Q&A PET/MRI  | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Q&A PET/MRI | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Program Implementation | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
Program Implementation | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
Outcome data | Uterine Artery Embolization The Good, The Bad, The Ugly
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Pulmonary Ablation | Interventional Oncology
Pulmonary Ablation | Interventional Oncology
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Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Overview of Diagnostic Errors | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
Theories on Accident Causation | Looking for risk in all the Right Places: The Anatomy of Errors in Healthcare
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PET/MRI Case Study #2 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
PET/MRI Case Study #2 | PET/MRI: A New Technique to Obtain High Quality Diagnostic Images for Oncology Patients
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Transcript

positron emission tomography is the use

of a radioactive tracer in this case FD gee her fluorodeoxyglucose to assess the metabolic activity of ourselves ftg is tagged with glucose and glucose is used by our body for energy cancer cells are thought to be our Armour hypermetabolic

so if we inject FDG to our patients it goes to areas with hyper metabolic activity this area is called a hotspot and when a hotspot is noted in a PET scan its it's thought to be cancerous this is an example of a hyper metabolic

region noted in the pelvic area of the patient this patient is diagnosed of cervical cancer and what is MRI as you all know MRI is the use of radio frequency currents produced by strong magnetic fields to provide detailed

anatomical structures it is the preferred method for imaging soft tissue organs and there's no ionizing radiation present now what is pet MRI pet MRI is a combination of these two modalities instead of going to two scans using two

scanners we have one scanner that is able to obtain pet and MRI images simultaneously so why can't we just call this pet well we run through a few problems we have fdg-pet CT where it's a PET scan with low-dose CT accompanying

it and there's fdg-pet CT with diagnostic CT we're full sequences of CT is coupled with a scan and a pet MRI always has a diagnostic MRI done with it

establishing a few things I know that we may have a mixed crowd here and so if I'm saying things that you're like oh come on Newsome we already know that

just just rush me along but if I'm if I'm repeating some other things that that are more interesting then you can slow me down so it is no surprise and I'm often frightened when people say that fibroids

are along the spectrum of cancer fibroids are non-cancerous tumors of the uterine muscle if you remember a little thing about Anatomy that the uterus is made of three specific layers the myometrium which is the main muscle of

the uterus the endometrium wishes the inside part of the uterus and the serosa wishes like a saran wrap of sorts that keeps the whole thing together fibroids are made of the main muscle portion of the uterus and we don't know what it is

but something happens and it turns that muscle portion of the uterus on and when it over grows it grows into a ball and we refer to that ball as a fibroid fibroids are the most common pelvic tumors in women it is the leading cause

of hysterectomy in the US and even though we've been doing hysterectomies forever one third of all hysterectomies that are done in the United States are done for benign disease and we know all kinds of sexy ways now to stop bleeding

you freeze it you make it cold you make it hot we have Lube cautery and all kinds of things and still in 2019 we can't stop the bleeding from fibroids which then result in women who are scheduled for

myomectomy to have a hysterectomy as a way of controlling the bleeding so there are a few other things that we know about fibroids we know that the symptoms are very varied depending on where these fibroids actually end up and

the symptoms of heavy bleeding still remains the most common symptom dysfunctional uterine bleeding abnormal heavy menstrual pain menstrual cycles pelvic pain and symptoms of bulk that is I cannot drink a can of coke before I've

got to go to the bathroom I know every rest stop between my house and where I've got to be every time I laugh or sneeze I pee on myself I'm doing 200 sit-ups a day and I'm wearing two Spanx if that is happening to you that's not

normal we also know that fibroids have a high impact on the quality of our patients lives and their productivity because if you can't go to work and you take off from work and you're really not able to

take your kids to the soccer game or do all the other things that you really want to do then I think that that is really quite disruptive of your life and yet women year after year suffer from these types of symptoms and do not come

to getting any type of treatment at all in fact they don't even tell their doctors about it because they just accept that as kind of normal and the average time from when women start suffering from these symptoms to when

they actually seek treatment is around three and a half years and I work in Atlanta and the average time is away above that and I would say to you that just go with me here and I'm sorry for any male that is in the audience that

will be offended but if you could imagine now now just use my own husband for example if he could not have an erection for two weeks in a row I think he would see the doctor immediately however women will wait for five years

with all kinds of symptoms and not actually seek any treatment forget an erection if they're constipated for two weeks in a row they go to see the doctor this is a real public health burden and I know that I talked about the survey in

2013 and where si are is doing a big thing called a fibroid fix it's available on the website we'll see if there's a way that we could link it to the avir website but just last year they repeated this survey of around a

thousand women but guess what these statistics had not changed around a third of the women continued to complain of this interruption in the quality of their life due to fatigue or cramping and three-quarters of these women still

prefer a minimally invasive uterine sparing procedure they still want to preserve their uterus even if fertility is not an issue and although I just told you that like 80% of black women will have fibroids by the time they're 50 and

70% of white women there's around a quarter of all women that have never ever ever even heard the term fibroids for a disease that is so common and this affects so much whim so many women and it is still so costly in terms of how

much days they have to take off from work and what they have to do in order to get treated we spend around thirty four billion dollars a year in the u.s. that is on par for the amount that we spend for colon cancer and ovarian

cancer combined for benign disease and yet not much has been done so if you're

I good afternoon everyone my name is Ross Lozada and today with Murphy Aldana we will be presenting pet MRI and you technique to obtain high quality diagnostic images for oncology patients we have no disclosures Murphy and I live in New York City it is the place with

over 8 million in population 3 million of which are foreign-born about 800 different languages are being spoken other than English and they love in floor MRI of Memorial sloan-kettering Cancer Center we are reflection of these

statistics we speak about 10 languages which includes Sigala Chinese Russian Korea and Albanian just to name a few and about 70% of our staff are foreign-born actually I can count in one hand or how many are born in the United

States but despite our differences we have a few things in common one is that we all love our jobs and we take pride at what we do and T in taking care of our cancer patients and also we love food

this is a typical potluck in our Union we love our pot Luck's we do it for every holiday for every birthday in even random days where we just say hey you want to eat here we have some stuffed cabbage some rice biryani some mac and

cheese and quiche some caldereta and adobo some curry goat and a Haitian rice called John John but back to our topic our objectives for today is to provide an overview of pet and MRI imaging modalities discuss the application of

pet MRI imaging of oncology patients describe the care of the patient undergoing paddan-aram identify the nursing implications and to review some case studies so what is pet pet or

we're happy to open up the floor for questions you want to use it maybe a mic for them yeah sorry oh let's use a microphone then everyone can hear Thanks

can you hear me on this one yeah so I think your question was how successful were we thank you for this presentation so I used to be six feet tall so I will tell you that the journey was very difficult and it's not for the faint of

heart it takes a lot of people to really make this happen and as I mentioned in 2013 we were working with the value Institute and that's where I grabbed Thome from I stole her shamelessly and you know we did some projects and I'll

say the first few were not successful and what we learned from that and I mentioned in my speech is that they don't understand data unless you put it and you present it in a way that's meaningful and that was hard for us and

and so yes it was hard so my so my point is that that this is really incredible and how I would use this and based on your experience how helpful was this to to increase your efficiency and for the nurses to actually look at this and say

oh my god you know this is what we have to meet and we're not meeting it so yeah so I will tell you and the journey was real I mean the perseverance was I mean it really was driven by Chris and Tomi they didn't give up and we met like even

when we started with the scorecards we met weekly with all of the supervisors in all modalities because we didn't just do this for IR Nursing we did it for all modalities and it was it was really hard in the beginning because I kind of felt

like that's where we talked about stories and numbers you know and I I talked about Nursing being a very story driven you know the frontline nurses want to help for their patients and when you show them numbers they start telling

you that all you care about is your volume and your data and you're just going to keep driving us until we get driven down into the ground and so it's no honestly and so it was how do we make that connection and I think to your

question we started with the scorecards as those were less impactful to the frontline staff but once we started using the dashboards and we just we slowly like rolled it out we started with

Huddle's first and we had like the charge check and the charge nurse talked about it and then other nurses and text would be around in the core and they would sort of listen in and maybe chime in about why a case was laid and what

have you and so we started doing the Huddle's and then once we rolled out the dashboards now we have actually a big screen up that runs the dashboard is visual um in the core of the IR a suite and it's really great we have there

actually it's so funny we have them an on-time start like glitter posters so it's on your like it gets posted on the outside of your door and everyone's involved before it was like the techs were much more driven about getting the

cases on time the nurses were less but now we've really actually the teamwork the competition of it and the teamwork it's hilarious I love seeing it they're like yes I've got like all my cases were on time today and they ran like room to

like a clock and so it's it's been very good and they've really utilized that the other thing I love is you know the work up stuff so after the day sort of you know winds down and they're trying to figure out like what were cups they

have to do or whatever I watched the charger she'll put up on there and say like we need you know we need to get this done or whatever so it's really helping to to show them like what work they still have to do so no

one's just standing around going I'm not sure what I'm supposed to do now you know the other thing I'll mention though that was important to getting there was so we took all the lead techs in every modality we call them education

coordinators in our modalities and Tommy did classroom work with them so they would come they would come every two weeks and sit in a classroom and Tommy would speak specifically to the reporting metrics and what it meant and

it did two things it not only taught them how to read data it also engaged them with each other and we cross kind of crossed the modalities where they were siloed in their work before it really built some teams among the

technologists and the nurses and Tommy spent a lot of time teaching them and it it it was very impactful so I would I would absolutely recommend that you have to have some kind of classroom work for this do you want

I think she um great presentation like this is quite inspiring you know it's really nice to see that you've able to build this up in accomplished and everything you did my question is more on a Don cases so when

it's scheduled its predictable you can try and work work things so that you hit everything on target but how do you deal with a Don cases cuz we I feel like in our in our area ninety percent of the cases I add ons so how do you how have

you been dealing with it are important and that was a lot of why we started this journey because a lot of what we would get is oh we have another add-on case and now the world and the sky's fallen over it was a lot of that

reaction to everything that was thrown on a frontline staff so I'll start from the scorecard let me start from the scorecards so on the scorecards we have the utilization numbers which shows how much of our

capacity were using and that was the first step for the team or for everyone to start to understand how much work can we actually do and how much of it have we and how much over that we utilize in today so if we are at a 50 or 60 percent

utilization we're not really at a high capacity utilization rate but then who still had frontline staff who thought add-ons were very chaotic and so it wasn't necessarily about the volume of work it was how we were managing it so

starting to break it down in this way helped everyone start to understand okay maybe it's not that we're doing too much it's how are we managing what we have so that was why the numbers were important to set that objective level of

understanding in the first place and then when it comes to the stat to the dashboards which is more frontline information because they have so we don't have the I our interventional radiology dashboard here

on that dashboard we can see the utilization in each room so we can see how much how much capacity there is to actually manage to add on more cases into each room so that's something that when they make decisions on add-ons they

look at each room and say what is the utilization currently do we have enough time to actually add on one or two more cases and then as Jeanne showed you in the nursing on the nursing dashboard with the caseload by hour of day they

can make decisions around what time of day is the best time to add on this case because we see we already have five at 8:00 a.m. maybe we should add this case on at 1:00 p.m. so it's really helping people make more objective objective

decisions around the add-ons or around their workload vs. reacting to everything that comes up so you talked

them so my particular area of interest is a blade of radium ization and what we'd like to do is to break the liver

down into a bunch of little tiny perfused volumes off of a single vascular pedicle or what we call angio zones and those are those allow us to segment out if you only have small volume disease for example like here in

segment three why do I have to treat the entire left to paddock low I can actually treat just that small portion just like it what it tastes only now I'm administering y9t but since it's expendable liver I

can administer doses that are way higher orders of magnitudes higher than what I could if our infusing into the liver just on its own so here's an example of that if you look at this lesion in the right of panic lobe you'll see these

little lines over them what we want to achieve is around a 205 GRA threshold for these lesions that's the red line everything that's south of red in terms of color orange Holly to blue is not cold enough to kill tumor so if we

administer a dose of a tea grade to the lobe we get this coverage which is to be a partial response if I administer 150 grey suddenly that red line gets larger what happens when you administer 400 grey now you've officially covered the

entire lesion and so you're going to lose the adjacent liver at those kind of doses and as well - what what the real question then is not sort of how much dose you give it's you give what you need to to ablate the tumor in its

entirety and you see what the patient's left with if someone's left with anatomically a lot of remnant liver because of how you've segmented out that lesion then go ahead and dose extremely high and that's essentially what we've

seen in pathologic results it's one of the highest things of high school pathological crosa rates you can achieve with a trans arterial therapy it's highly competitive with thermal ablation in the correctly selected bleezin

so this is an example of what it looks like when you segment out a little lesion like this and this patient ultimately went to resection and this was a complete pathologic necrosis but as you can see even it was a cirrhotic

patient we chose a very small volume of liver that we felt the patient would tolerate so that's a blade of vernalization let's take a look at what looks like in real time so we have a little capsular lesion we felt that

ablating this patient who was a potential transplant candidate we felt we can probably with a blade of radium realization so you go in and this is the comb beam CT that looks at a complete enhancement of the lesion within the NGO

zone this is what the MAA looks like when we administer it you can see how it tends to cluster within the tumor but you can see what the adverse territory is the liver adjacent to it this is what the engine room looks like how highly

selective it is the day of and this is what the wine ID actually looks like is the wine 90 doing its job and you can see how conformal it is there's no risk whatsoever to the liver that's adjacent outside of that field of

a maximum of around 11 millimeters and this is a patient at one month with a complete imaging response and this patient never developed a recurrent to the site and what's actually sole mode of treatment for this person's liver

cancer this is how you get complete pathologic response if you look at those little tiny grey dots in there those are actually the spheres within tiny little vessels within the tumor sometimes they go even to the portal branch but you can

see how they're not clustered uniformly but when you make them super hot that allows them to give range where otherwise they would be fine a little bit short so this also applies to the whole lobe this was a patient that had a

very unusual presentation of colon cancer that was invading the portal II we weren't sure what to do with this patient no one was because a very rare occurrence so we said well we would like

to resect him but there's not enough liver and we're not sure if this person's gonna survive because we've never seen portal cancer invading the portal vein so we said let's treat it with the radiation lobectomy and what's

cool here is if you look at the the arteries even though the tumor is invading the portal vein it's bringing arterial supply along with it like a vagabond and that's the conduit that allows us to treat these patients so

when we saw that we felt this patient we good candidate for irradiation lobectomy which is applying an ablative dose of y9t to the entire low not just a small segment in patients where otherwise cannot because of the anatomy the tumor

or if you're trying to shrink that lobe to get that person ready for surgery why because if you look at the size of the lobe on the left from this first image and compare it here you can see how much larger it got what happens is that part

that the surgeon ultimately tens on resecting in volutes over time and becomes completely vitalized and turns into scar tissue so we know that if a surgeon goes in afterwards to cut it out it's going to not result in liver

failure and that level of security allows people to have sir who otherwise wouldn't this patient is not going to have metastatic disease because we followed their blood level markers let me see how low they are and

is going to have enough liver remnant so the patient went to resection and this is the pathologic specimen and this was also a complete pathologic necrosis so I

study I would like to share to you in personal note that my training school

books and experiences never prepared me for all the different types of cancer I have seen while working at Memorial sloan-kettering I have come to realize that cancer does not discriminate it doesn't matter how old you are

socioeconomic status gender race color of your skin and geographical location and religious beliefs and taking care of the young pediatric patients makes me the saddest if cancer hits you it hits you

the youngest patient that ever took care of is two months old infant diagnosed with glioblastoma I remember that day clearly because I booboo the whole day based on this here comes the third case study this is a four year old child

diagnosed with hepatoblastoma a pet MRI with anesthesia is done the image to your left is pet and on the right is pet MRI you see the difference in the images this scan is done for the doctor to evaluate the extent of the disease you

could see there is a hypermetabolic uptake in the liver and in the pelvic area the color red on top of the head the patient that's normal that's a normal uptake there is no increase in the uptake so this considered normal

we're gonna do our closer look and I would like to show you the difference between the PET CT and the pet MRI the image on the middle is the PET CT done on March you could see how where are the areas that are you could see all the

increased uptake on the areas like the chest the neck thoracic region and the abdominal region the the bright area there at the bottom Dustin or my bladder up take look at the image on to your right that's a close-up loop of the

sagittal PET CT done on same month you could see clear I could see where the location of the abnormal act uptake are circled by the the white circle there is abnormal uptake in the spine and in the chest and

of course where the hepato blastoma is located but looking to your left that's the bet MRI you see how the image is so clear and defined you could now count from the you could count where the exact location is it's on T 11 and is in the

vertebra and there's evidence of the actual cord compression with all you know all you know is a neuro emergency this is a four year old child and the other abnormal app takes you could see also so this child don't only have

hepatoblastoma but also have OSHA's metastases so the scan is done to evaluate the extent of the cancer the last cases study is the 41 year old

strategies so some things that we have

in place right now our peer review Grand Rounds CPOE this is one of my one of my favorite process improvements is is making the right thing the easiest thing and you do that through standardization of processes so that's standard work so

that's your order sets that's the things pop-ups although you don't want to get into pop-up fatigue but pop-ups help our providers for little gentle reminders to guide them to what's right for the patient and to cover everything that we

need we need to cover to ensure the safety of our patient so recently in the fall of last year we had a TPA administration err that occurred it involved a 69 year old patient who two weeks prior had had some stenting in her

right SFA she presented to our clinic when our clinics with some heaviness in her leg and some pain and when she was looked at from an ultrasound standpoint it was determined that her stents were from Bost so she was immediately taken

to the cath lab and it was after angiography did indeed show that there was clot inside these stents they did start catheter directed thrombolysis in the cath lab they also did started concurrent heparin often oftentimes done

with CDT what's usual for our institution is that we have templates that pull in the active problem list for a patient in this case the active problem list or a templated HMP was not used had they

used the template at agent p they would have found that the second active problem on this patients list was a cerebral aneurysm so some physicians will tell you some ir docs will tell you that's an absolute

contra contraindication for TPA however the SI r actually lists it as a relative contraindication so usually we're used to when you when you start a final Isis case you know you're gonna be coming in every 24 hours to check in

that patient in this case we started the the CDT on a Thursday the intent was to bring her back on Monday the heparin many ir nurses will know that we will run it at a low rate usually 500 units an hour and we keep the patient sub-sub

therapeutic on their PTT although current literature will show you that concurrent heparin can also be nurse managed keeping the patient therapeutic in their PTT which is what was done in this case so what ended up the the

course progression of this patient was that so remember we started on Thursday on Saturday she regained her distal pulses in her right leg no imaging Sunday she lost her DP pulse it was thought that it was part of a piece of

that clot that was in the the stent had embolized distally so they made the decision with the performing physicians they consulted him to increase the TPA that was at one milligram an hour to 2 milligrams by Sunday afternoon the

patient had an altered mental status she went to the CT scan which showed a large cerebral hemorrhage they ain't we intubated to protect her airway and by Monday we were compassionately excavating her because

she me became bred brain-dead so in the law there's something that's called the but for argument so the argument can be made that this patient would not have died but for the TPA that we gave her in a condition that she should not have had

TPA for namely that aneurysm so this shows how standard work can be very important in our care of our patients and how standard work drives us down the right way making the easiest thing the safest thing so since that time

we've had a process improvement group that we've established an order set specifically for use and thrombolysis from a peripheral standpoint and then also put together a guideline that was not in place so it's some of that Swiss

cheese that just kind of we didn't have a care set we didn't have a guideline you know we didn't use our template so all those holes lined up and we ended up with a very serious patient safety event so global human air reduction strategies

oops sorry let's go back these are listed in a weaker two stronger and some of what we're using in that case is some checklists so we developed a checklist that needs to be done to cover the

absolute contraindications as well as the relative and it's embedded in the Ulta place order that the physician has to review that checklist for those contraindications and also there to receive a phone call from pharmacy

just to double-check and make sure that they have indeed done that that it's not somebody just checking it off so we have a verbal backup sorry so the just

anatomy of ayres in healthcare so this

is according to ashram which is the American Society for healthcare risk managers this is my professional organization and what they say is the anatomy of patient safety errors is that we have a blunt end of the system and

then we have a sharp end of the system and the blunt end of the system you'll find your organizational factors like your culture your policies your procedures and regulations and you're gonna pass through those things that we

know all too well which is our environmental factors that have to do with our equipment our staffing our resources and our constraints and lastly we come to the sharp end of the system which are you and I at the

bedside alright so and this is where our human factors come into play if we are we have a lot of tasks overload under load communications not quite where it needs to be we're fatigued or stressed we're

thinking about other things our blue wall that we like suddenly turn beige so clinical competency comes into place here also the skill set of the person so your managers out there it's very important to know the skill set of your

people and of course our Kunik communication skills so patient safety used to focus on the sharp end you may remember a time when a patient safety event happened and you got called into a room with a group of people and the

event was on powerpoint slides you go through the event and then you're asked a lot of questions from this lineup of people and you it feels very much like the Inquisition well what we found was that wasn't very helpful at getting to

the root of the cause because oftentimes it's not the person it's what is happening in the organization that leads to that event the workarounds that we have to do because we know that a policy and procedure really needs to be tweaked

it's not representing the practice that we do any longer so we focus now risk management focuses on the system what was the system ere and how can we fix that and we do that now by interviewing the people who are involved with the

event and one of my favorite questions is to ask if you had to do it all over again what would you do differently that's my favorite question because it really lets me know what needs to be changed from an organization standpoint

and then that's when the leaders come in so then we get together with the eaters and sit down with the leaders and effects some real change for our staff at the bedside all right education

this is nursing case volume per hour so

staffing is a consistent challenge as I mentioned before having dashboards helps to make real-time decisions to help allocate nursing resources during high-volume times so this dashboard indicator

identifies the distribution of nursing workload over the course of the day I love this one for me especially as a nurse manager especially since me knows Tommy says they they feel like oh my god it's so busy it's so busy it's so

chaotic and you're trying to help them you know well of course I understand why it is now so I actually have data to understand their story and help them to see the data and why they feel it's chaotic so again with the help of color

coding the ability to look and interpret the data is simple so here since I've taken you through a few I thought I'd throw it out to everybody and see what if you wanted to kind of take a stab at using our model so if showing or if

anyone wants to raise their hand so what are you seeing here in this dashboard a lot of what you owe to our cases yeah anything else are you seeing yes correct there's nothing happen at 8 o'clock anything else right yep

sort of a lull here correct so what might you interpret from that in other words so what would you kind of see your say about this I'm sorry can be allowed a long time oh yes yep exactly right and so so then

what action might we take here to help sort of get rid of sort of the high volume times yes exactly so here's where you would shift the staffing to help cover the high volume areas and so I'll just take you through what how since

it's what we do at D H I'll take you through so exactly right I think someone pointed out that you have nurse cases except for say at 8 and at 6 and 6 generally we're just doing recovery at that point we don't need any more cases

going through interpret wise so we have this Pio nurse as you can see in the magenta and I'll tell you a little that's our MRI nurse to specific for MRI doing Pio sedates as Chris mentioned we have an MRI nurse there and we also do

cover pacemakers as well and those that's her caseload as far as non sedation we actually just have we sort of as people aren't busier in between rooms is when they might go you know give lasix for a year gram or you know

port access or what have you so what I'm looking as interpret I have a Pio nurse available seven several times a day so only in the magenta is she busy or he and then the best times may be for IR addons is between like say 11 and 12

here I would potentially my action would be to say hey this pio nerves could actually come and help get cases started and get them on time and then also come and maybe relieve lunches that's another I'm sure probably an issue for everyone

is like you're down a couple staff during that time but we're still running our rooms great that was a great job very good okay so a couple more to just kind of quickly show the pending patient workup documentation so this gives the

ability of the frontline RN to have instant visuals of the electronic medical records documentation that needs workup and phone calls that are needed to be completed for future patients so again let's use our model

so look there are a lot of workup phone calls pending and remember this is real time so in this case if you were looking this is just a snapshot but say today is March 4th okay going around so the first thing I'm saying yep there's a lot of

cases I've got 14 here and it shows a couple of days worth obviously you can see how the numbers add up I'm looking at the high number of same-day pending work for procedures so you can see here three four five six work ups and I have

nine phone calls to be made and I'm looking at the MRI work up calls and right now there are a couple days out so I'm opening less concerned about that so how would I apply and what action would I take well first I would clarify that

these same day workup and phone calls are actually pending sometimes they might have been done or someone missed hitting the icon on our computer and then I would prioritize completion of pending work so I might say to a couple

nurses that are in between rooms or whatever can you make a couple of phone calls we've missed this and we need to get contact with the patient and then of course I would obviously prioritize the I our work ups before the MRI ones

because there are a couple days out okay

to our case study the first case study is the normal whole body pet MRI the the

image song to your left it's a regular pet MRI the one on the right as you could see it's a big difference there is very vivid image and you could pinpoint the organs they are not to me of the patient this is normal

scan there is normal uptake on the brain the ureters the bladder the kidneys those are normal there's no abnormal uptake or there's no hypermetabolic uptake noted the next case study is a 59

gets pet MRIs right now our main focus are our oncology patients it helps us

determine the type of cancer they have the diagnosis of cancer assess disease progression treatment therapy and treatment planning and some antecessor treatment response so let's say a lesion is FDG avid and

has low blood perfusion that would help our physicians to us to say what kind of treatment they can give to the patient pet MRI is also good for patients who can tolerate longer scans right now it's a very young modality

there's still a lot of research goes on with this and coupled with that is advantage of research right now we actually in the Memorial sloan-kettering we have started using this instead of FDG we've used gallium 68 of to assess

neuroendocrine tumors who have also done cervical lymph Austin Tiger phim where FDG is injected directly at the patient's cervical cavity and that helps map out the lymph nodes in the survey in the pelvic area this can be used by the

surgeon and see what lymph nodes can be sampled during the surgery we provide some education and assessment before during and after the pet MRI we assess for the patient's allergies we tell the patient's they have to be NPO at least

six hours prior to FDG injection as for our anxious patients they often come pre-medicated and this just comes with some care coordination with their physician the physician would prescribe some low-dose anti-anxiety medications

and the patient would take it an hour before their test as for our claustrophobic patients we what we have done is we let them see the Machine we let we let them feel the Machine we put them inside if they would want to and it

would be up to them if they would be tolerating the scan we assess for their diabetes regimen and my refe will speak more about that later we assess for patients pregnancy status on patients loving to fifty years old process for

their breastfeeding status and screen their implants during the pet MRI we tell them about the coil placement we give them an emergency call bell and we tell them to decrease their movement well being is like although our some of

our patients would say I didn't move but then the image so differently there there's a possibility that the magnet can induce some involuntary twitching after the MRI we tell them that they can resume their

diet they can resume their diabetic diabetes regimen and as if they get MRI contrast they can pump and dump for about 24 hours after the test but if they don't get a contrast they can keep their breast milk inside the fridge just

to help to decay just to decay the isotope that was given to the patient it doesn't give any harm to the baby

get into human factors engineering so James riesen who were going to talk a little bit more about said we can't change the human condition but we can change the conditions under which humans work and this is the discipline that is

human factors engineering so it's a discipline that takes into account human strength and limitations in the design of interactive systems that involve people tools and technology and work environments to ensure safety most

notably or most recently they were involved in the restructuring or re-engineering of anesthesiology machines so you may remember a time when anesthesiology machines didn't even have a monitor a

patient monitor on him they were just the machine and they had the bellows on them on top that would go with the patient respirations so since that time they've been written a re-engineered to include a patient monitor further

reengineering took in human factors which is is the human condition and I'm going to get into some of those human factors a little bit later but we they took a look at the monitor to make it more clear and intuitive for the

anesthesiologist they also took a look at the alarms of these anesthesia machines to make sure that they were accurate and had a better range to prevent alarm fatigue and then lastly they put in some automation into those

machines human factors engineering is also used outside of healthcare in aviation automobiles so the backup camera that we enjoy at our cars that came from human factors engineering and also a Three Mile Island they used human

factors engineering when they looked at that accident that nuclear accident that took place those many years ago and they used what they learned from Three Mile Island to design much safer patients say sorry nuclear power plants so it's it's

not only used in healthcare but throughout all of our industries so

program is the stuff requirements and

stuff education all personnel who works in this department the radiology department have to complete successfully the web-based training for level 1 and level 2 safety MRI training including the housekeeping

and also the hospital staff that comes to the department have to fill up a screening form after doing so you'll be given a sticker placed in the back of your ID and it's good for a year and that serves as your pass coming to MRI

so you don't need to fill it up every time you come in and the initial radiation safety training is given by our safety radiation safety officer in the start all it's on higher and also the best training for RT Sundarbans

course training to nuclear med and the pet department it is important if you work in the radial pharmaceutical area that you know the basic concept of spill management the acronym cares I would like to acknowledge that this acronym is

done or formulated by our nurse leader le carré leer C stands for contains pill and opened the checklist the checklist should be available or posted to all areas where major pharmaceutical agents are administered a s alert the

technologist and supervisor they're very knowledgeable in taking care of the spills our is to restrict the area don't let anyone come in and step onto his areas of spill remove the patient if possible he is to educate the patient

you have to reassure the patient there is no health hazard or nuclear hazard to them yes is to sanitize sanitize the area of spill and record in the medical record is very important but what to do when this bill occurs in the zone for of

the MRI we were prior to going that I would like to show you the how our Rachel active spill checklist looks like this is formulated by Pierre Robson it would take you I would give you guidelines on how to do step by steps in

case of nuclear spill and what to do for spills that occur in MRI so on for first cover the area with absorbable material remove patient from stone for prior to proceeding to the decontamination process contact

radiology leadership they're the one to direct surface contamination within zone four and remember the Geiger counters are MRI unsafe so how we check the Geiger counts you have to use an absorbable material you keep wiping and

then bring it out and measure the Geiger level until you keep doing that until it gets cleared also remember that the MRI magnet is always on so have someone is done guard outside the door so anyone that would need to go inside the room

would have to be scanned again and screen this is our ms KCC clinical

Sean I know you have not seen these slides at all you wanted I John can talk about this with his eyes closed so it's

not like there's anything but this is the data that was published from the Jade publishing jvi are from what Sean has written and it's just the current standards relating to what you should be expecting what we tell our patients that

they should expect for outcomes as it relates to uterine artery embolization again I'm not really here to try to point this I know you can google these you can get the information yourself but just to say that all of our procedures

have risk and we need to be clear with our patients about them now I believe that with all of these risks combined the benefits of doing uterine fibroid embolization for most patients is far greater than the risk and that's why I

really do have my practice so these are the benefits right shorter hospital stay and I would say more cost-effective and that is really debatable because gynecologists have become smarter and smarter now they're doing like same-day

hysterectomies if you have a vaginal hysterectomy then maybe a UFE is not as cost-effective because they don't have to do an MRI beforehand and they don't get an MRI afterwards and do all of that anyway and if you look at the long-term

cost of that then maybe having a hysterectomy in some patients could be that but we know for sure that patients are more satisfied when they get a embolization procedure than in my MEC to me not in the beginning run because the

procedure can be very painful that is not the procedure itself is painful but post embolization syndrome which could last anywhere from five to seven days can can be very painful again this is the comparative data that was published

by dr. Spees who is our gold medal winner this year understand a lot a lot of work in this space has allowed us to have this conversation with our gynecology partners but also with our patients as we talked about like when

can you return to work how long are you going to be all for you know am I going to need extra child care or whatever how long would I be in the hospital this information helps us to inform our patients about that then on average

you'll stay in the hospital around you know a day or so and most uterine artery embolization procedures are same-day procedures and interventional radiologists are doing these in freestanding centers as well as other

providers without any issues so we're almost down to the end we know that fibroid embolization is proven to be an effective and durable a procedure for controlling patient symptoms it's minimally invasive and it's outpatient

most patients can go back to some normal activity in one to two weeks it has a low complication rates and some patients mein neatest to surgery and should have surgery so in our practice we send around 1/3 of our patients or so to

surgery and the reason that that is that high is that patients are allowed to come and see myself or dr. de riz Nia from the street they do not have to be referred from their gynecologist and so they're just coming from the street then

you will be referring them to a gynecologist because of some of the things that may not make them a good candidate for embolization such as this

MRA safety is one of our top priorities in our unit we have set up MRI zones zone one being the patient waiting area

zone two is where they change and they get screened zone three is where our control room is and anyone who passes by zone three has to get screened our pet MRI injection room is actually inside zone three and zone four is an MRI

scanner itself we assess risk in our patients for their implants we were iterate to them the importance of bringing their implant card with them just so it's easier for us to assess the compatibility of their their implants

with MRI right now we have the capability of scanning cardiac pacemakers and defibrillators it just needs more coordination with our in-house cardiology service and the implant representative rest assure

expanders and aneurysm clips are so contraindicated inside the skin we tell our patients to remove some items that they are able to remove such as dentures hearing aids piercings and prosthetics if they have it as for radiation safety

we observed the concept of Alera or as low as reasonably achievable you know before we inject the patient with the isotope we keep them comfortable we give them blankets we give them the pillows and we tell them

after they get injected that they are radioactive so we try to limit our exposure to them after they get the injection now we try to keep our distance from them and we have shielding lead shielding within the pet MRI area

now we have lead shield syringes available for the nurses use and we have dedicated a hot hot bath room a hot room and radio pharmacy we Ritter we give these puppies this injection card to the patient after they get the scan and we

were either a to them the importance of this card we have the stories from our patients where after the after they scan gone home and they passed through the tunnels or the bridges that they actually have been pulled over by the

police because the police have very sensitive radioactive detectors there was one patient who may have forgotten his card may have lost his card and he got pulled over and the police had to call our institution to confirm that he

really did have an isotope injected we

so let's talk about a few of our key

patient safety influencers so the Institute of Medicine came out with a landmark report called to err is human building a better health system in that report they stated that health care in the u.s. is not as safe as it could be

or should be and at that time there was forty forty four thousand two ninety eight thousand deaths occurring due to medical air so they defined medical error as the failure of a planned action to be completed as intended or the use

of a wrong plan to achieve an aim the number comes as the IOM quantified through a 1984 Harvard patient care survey they also estimated that the reporting of preventable adverse events is underreported so these are our near

misses these are our opportunities for change and those are underreported but it did support a collaborative relationship with quality improvement and just to note that not all errors result in death okay so as you could

well imagine this report met much scrutiny and had a lot of comments that came out the next one the next report is the future of nursing leading change in advancing health that came out in 2010 and in that the IOM called for nurses to

take an active role in preventing patient safety airs and they asked us to step up by practicing to the fullest extent of our education and training and from that time we saw a lot of academic advancement to terminal degrees so a lot

of doctorates that's the DNP started coming out we saw a lot of nurses advancing from Associates to be a sin BSN to masters etc to terminal degree our next influencer is the Committee on quality

healthcare in America and they had a project in which they focused on the 2001 IOM report which is crossing the quality chiasm a new health system for the 21st century now a lot of things came out of this report with regards to

the the government latched on to this one with some of our advances for quality care they have some specific objectives for improving healthcare delivery specifically they were revolved around six aims and those six aims were

safe effective patient-centered timely efficient and the equitable provision of healthcare but they noted that the biggest challenge was going to be establishing a culture that encourages reporting of events of our patient

safety events that may result in either actual or potential harm to our patients or others and this culture was actually known as the just culture which is we're gonna discuss a little bit more a little further next we have the National

Patient Safety Foundation so they're a central voice for patient safety they also promoted the patient safety awareness week that I spoke about so the NP SF enhances patient safety awareness through educational programs

research project grants awareness campaigns and they encourage patient and family involvement so many of your organizations may have patient or family liaison groups that work with your nursing administration or your

leadership in looking at the patient care experience during a hospital stay and how that can be improved and also as it relates to patient safety events that may happen are near misses those may also be

discussed with patients and family to get their perspective on how we could improve the Leapfrog Group is a coalition of for fortune 500 companies and what they do is they they buy health care but in order to get them to buy

your health care you have to meet certain patient safety standards that they have such as CPOE so computer physician order entry also ICU physician ICU physician staffing standards sorry and there are a number of other things

that they look at as well the agency for Healthcare Research and quality the AHRQ this is where a patient safety and risk we live here there's a lot of a lot of the patient safety event systems reporting systems that are out there are

based on AHRQ fundamentals that way we can benchmark across the nation on how we're doing with patient safety events so the last one is the Joint Commission and they have their national patient safety standards all right we're gonna

workflow for pet MRI upon arrival the patient have to fill out questionnaires the MRI screening for contrast and allergy assessment pet screening form

the RT will review MRI screening for after he checked that the patients at MRI safe and no presence of a Mia Ferris fragments or anything he would give the paper to the RN the patient then will be escorted through the change room and

asked to put on robe and non slip shots this is these are the responsibilities of the nurse in our clinical workflow for pet MRI RN to review pet screening form and contrast questionnaire if patient have to receive gadolinium check

kidney function EGFR below 15 you notify the radiologist except for a of s below 30 you notify the radiologist check for allergies if allergic make sure patients is properly pre-medicated

check for Medicaid presence of medication patches and implanted infusion pumps now also you have to check for patient's blood glucose monitoring I have one but I would but I don't go inside the scanner so I'm safe

check for pregnancy status with pediatric patients we have a special process to follow the iron then obtains blood glucose and record if blood glucose is 70 to 199 we proceed with the scan anything above 200 we follow the

glycemic management with PET imaging flow chart and here's how our PET imaging flow chart looks like it looks complicated by its color coded it's three pages but I would like to show you some key points like the administration

of insulin is also based on the level of BMI you see on the arrow says BMI below 25 and there's another flow chart is if it's above 25 after that the patient will be brought back to the pet designated injection room

remember our pet MRI is located in zone three of the MRI area so prior to that the RT would the screen the patient again the patient would pass through the wall-mounted metal detector and nobody could go into song free without escorted

by the IRT or a nurse you have to swipe your ID to open the door mission when the patients in the hot room are in would obtain the height in centimeters and weight in kilos after that the RN now could do IV access once

secured you call the range of pharmacists that you're ready to inject so we wait until and the FDG dose would come up through the pneumatic children this is how our hot lab looks like the pneumatic tube to your left above is the

shower and we have the hoop to prepare for the dose or check for the dose and the wash station and once the those arrives the nurse injecting and the RT is scanning or the RT assisting just always two artists in one machine in our

MRI Department we have four magnets and only one is for MRI PET MRI it's always two artists in each machine so one RT is assisting you and with the patient so once the FDG arrives we do a patient identification using two patient

identifiers we check the label and the dose if it's correct the FDG then will be injected to the patient once injected we tell the patient they have to wait for 40 minutes during this time we instruct them to stay still not stay

still but limit movement and stimulation and inform them that we have a camera inside that room and the nurses in a and the nurses could monitor them in the nurse's station one RT will set up the scanner and computer

and patient will be screen and wondered prior to so on for so you get wandered twice check for ferrous presence patient then will be positioned on the scanner table by the pet mr technologies it takes 15

to 20 minutes for setup you have seen how the patient is position the whole body is covered by the coils and head is covered by another coil as anybody among he works in the institution who requires time out prior to injection raise your

hand please at ms KCC we do this is done by the injecting nurse and the RT is scanning the RT is reading information directly from the monitor not anywhere in the monitor while the nurse is comparing and listening into the using

the documents on hand this is done to ensure the five rights the right patient the right scan the right area your scanning the right contrast those and rate and method of administration as you all know is either given IV push or by

the dynamic or the injector timeout will be done if patient will be receiving gadolinium once the scan is finished IV access will be removed our artists are trying to remove and inject also so they are capable of removing the IV the

radiation card will be handed to the patient and paste after that patient would be assisted to the change room and discharge there is good thing when you change the patient into the robe and the non-skid

sucks because just in case there's a spill you're not sending that patient into the paper outfit they're not gonna be happy at all now I'm gonna bring you

so one of my favorite age-old questions is okay so how do you know that I don't have a cancer and I don't know because cancers can exist were there fibroids and we know a few years ago there was a black box warning put out for a more

salacious device which is how most UI ends remove large fibroids and that was due to the fact that if you go it looks like a blender of source like a handheld blender and it just kind of blends up big fibroids so that they can move it

out in chunks but if a fiber but if a fibroid existed in the uterus where there was an indolent cancer and you blend that whole thing up then you've just made everything a little bit blood-borne then something that was not

meant to be an aggressive disease process is now accelerated to an aggressive process and now those patients who had worse outcomes and that's why the device is still having a black box warning and is off the market

but it has really not that much to do with fibroids becoming cancer it's just that they both can exist in the uterus and if you are doing a uterine sparing procedure you could be missing a cancer having an MRI beforehand helps us out

just a little bit and we have discovered many cancers of patients that are asymptomatic in that way and they look kinda like this so when you look at these two and I'm telling you that the person on the left

those dark round things that that's a fibroid then you could probably see the thing on the right and say well that doesn't look quite like the thing on the left one looks like it could be a fibroid one maybe not so much so this is

a patient that came to see me in clinic and she had bulk symptoms she brave though she had bleeding symptoms she decided she was going to have a pair of white pants and she worried that day two clinic

but you can see where and I'm not able to point this out so I'm hoping that you can really do see that where she has her navel which is a dot that little crease on the MRI and then her uterus is above her navel and II and you can see that on

her and when I touched her abdomen I could tell that this was no fibroid at all so we had her image and done on the right hand side and it too looked very abnormal and so she went on to have a hysterectomy this was a cancer again

two other images that really talking about how MRI although it helps us to tell whether the fibers of vascular or not that it can also help us to find other things such as this person that has an endometrial cancer also very

aggressive cancer and they presented the exact same way abnormal bleeding and painful bleeding with clots so blood bulk symptoms with bleeding MRI not so much this is a cancer all right so what do I tell my patients when I see them

and they say dr. Newsome could I have a cancer I tell them what the FDA says the FDA says that there's a one in 350 chance that's what's on their website that you have a cancer and you have a fibroid at the same time but that's

really really high the American College of obstetrics and gynecology actually put out a position statement and revised that and they said that's way too high and they said it was somewhere between one and five hundred and the SI are with

dr. Spees looked at that number and said well we didn't think that it was that high either it's somewhere one in 750 or 800 so sadly I'm into big numbers so I just round it up I tell patients that's like a one in a thousand chance that you

can have a fibroid there and I'm gonna get an MRI and I'm gonna see if there is any chance if anything looks suspicious and the good thing is that I'm gonna keep seeing you for a year in a year after so that if I've missed something

then we're gonna be able to see it I said before that I'm super proud that I'm from Emory I'm from the home of dr. Chandra schnell who I had told to come and help me to give this talk but because I was running behind I hope he

doesn't feel compelled to come but we have put out our criteria and standards of practice for years that helps to inform us this is not something that is oh so new this is something that has level

evidence to support one of the the procedures that we do and this is very unusual for the things that we do in NIR where we have level 1 or level A's evidence that says that and because of the work that the society has done and

no doubt some of the people that are in this room I know for sure Julie was involved because we were doing these when I was in Alexandria the the trials to answer this question the American College of obstetrics and gynecology had

to adopt this as a part of their position statement to say that based on the long and short term outcomes uterine artery embolization is proven to be safe and effective option for appropriate patients in selected women who would

like to retain their uterus and that is still there a position statement today although I'm aware that they're revising it they're revising it because of the

now let's look at non-invasive ventilation and I know about like five

percent of the patient population that you are seeing is on some form of non-invasive whether they're on by level ventilation or continuous positive airway pressures right so see if HAP using to stent the Airways open and

maintain a pro a Peyton airway and improving oxygenation but BiPAP and patients that need co2 elimination right need help with the by level support so there's a lot of questions that come up when we give

these talks I'm like how does capnography work effectively with these different technologies of non-invasive ventilation and especially because more and more of our patients are requiring these so we're gonna look at some of the

comparisons of co2 capnography data from three different sample sites and remember I showed you that picture so that picture I showed you with the patient wearing the sampling line with a nasal oral scoop and then there was the

mask sampling port and then there was the port on the ventilator circuit distally so that's what we're looking at here so the diamonds that go I wish I had a pointer I don't have a laser pointer I'm sorry but across the top the

diamonds represent our end tidal capnography values from one liter all the way up to eight liters so as the props are as the pressures go up for CPAP they were monitoring leak rates and what they found is the cat nog rafi

values across all of those were pretty accurate when we're monitoring right here the squares and the diamonds represent the mask sampling port and the the ventilator in the circuit distal to the mask and as you could see that

quality of our monitoring goes down as we progress okay to use yes but just know the limitations of your equipment right and again this is the same thing for our BiPAP Dave data are by level ventilation we're seeing again

across the top if we're sampling right at the airway we have pretty consistent readings but then they start to fall off and we look at the other devices that are further down the downstream what we're seeing here is our end tidal

measurements again with CPAP data and what we're looking at is the patient leak so there's always leaks right when we have these devices on and that's a question well sue if I have a leak how accurate am i okay so now the red is our

nasal oral scoop and if you look at the red graph all the way across depending on the leak rate pretty consistent values right the charcoal color is the mask sampling port and that's pretty consistent probably until about like 10

right until our patient like leak rate 10 liters per minute coming out of that mast and then that value starts to fall off and even more so even further distal down our circuit when we're sampling from the circuit at the past the mask

that's the cream color pretty accurate when there's a minimal leak but as the leak goes up that falls off pretty significantly and the same holds true for our by level ventilation pretty similar distribution here with the

patient leak and the sampling so when we're using non-invasive ventilation yes it's accurate and yes it's accurate we're using high flows and yes it's accurate if we have a huge leak only if we're sampling right where the patient

is exhaling so now I hope that clears that up with the patients that are getting supplemental pressure support with your sampling and you know in those just whatever it can sample from the mouth and the nose right at the source

of exhalation has proven to be the most reliable out of all of the different sampling devices so third evaluate your

so we have some human factors that reduce situational awareness situational

awareness is our mental model of the world around us so I'm sure you're all very familiar with your interventional radiology rooms your CT rooms your MRI rooms and it may take you a little while because of

different human factors that are going on many of which I have listed here to realize that perhaps over a weekend weekend a blue wall got painted beige so some of these factors are insufficient communication fatigue and stress task

overload tasks under load group mindset press on regardless mentality have you ever had that from some of your Doc's in the IR room it's like you've got three cases to go and you know it's getting time that you know your staff have been

there for a while and they're let's push on we gotta get these cases done we're really opening ourselves up for air so again here's that action versus non action so we could really have some of that non action and maybe reassess those

patients and see if we can't have them wait till the next day it's a little bit safer to do those procedures and degraded operating conditions so I have a little test ready all right so this is actually a commercial that came out of

the UK and the UK was using this to heighten awareness for their drivers for motorcyclists being on the road but what it goes through is that we have a kind of a clue a clue ask type of setting where we have our trench coat detective

and we have a lineup of suspects for the murder of Lord Smythe who unfortunately is there on the floor and he's going to go through his lineup and ask them questions and he's gonna name the question but this is about the

world around you I want you to pay attention not only to what's going on but there are things that are happening in that environment that are changing and I'd like you to see how many you notice while you're watching our

detective go through his inquiry clearly somebody in this room murdered Lord Smythe who at precisely 3:30 4:00 this afternoon was brutally bludgeoned to death with a blunt instrument I want each of you to tell me your whereabouts

and precisely the time that this dastardly deed took place I was polishing the brass in the master bedroom I was buttering his Lordships scones below stairs so what I was planting my petunias in the potting shed

cussed of all a rest lady Smythe but how did you know madam has any horticulturist will tell you one does not plant petunias until May is out take her away it's just a matter of observation the

real question is how observant were you all right so how many changes did you happen to see I was gonna say would it surprise you I hit stop it in time um would it surprise you that there were 21 changes during this little yeah yeah

right yeah so how many caught late about five yeah but yeah right right so that's why communication is important and it is often one of those human factors that we don't pay attention to how key communication is in

preventing patient safety errors so let's take a look at what we what we did or didn't see clearly somebody in this room murdered Lord Smythe who at precisely 3:30 4:00 this afternoon was brutally bludgeoned to death with a

blunt instrument I want each of you to tell me your whereabouts at precisely the time that this dastardly place I was polishing the brass I was buttering his Lordships scones below stairs or something but I was fucking my petunias

in the potting shed touch the ball arrest lady Smythe right right originally yes is to increase that situational awareness where you've got motorcycles coming in from sides or in front or behind you or coming you know

all different directions that's what that was originally done for but there are a lot of those situational videos that are out there the probably the most famous is the one with the gorillas and you've got like I don't know ten people

that have the basketball and they're in different shirts and the task is you're supposed to watch the number of times that the white shirts versus the black shirts catch the ball right and in the middle of it comes this dancing gorilla

and most of the people miss the dancing gorilla because you're so focused on watching the ball well the same thing here you're so busy watching our trench coat detective interview to get to the end who did it

cuz you know they're gonna tell you I told you who's that they're gonna let you know who did it that you've miss all those things that are occurring around you so the reason why I did this is because it does involve a lot of

situational awareness and and situational awareness is around us every day and when we're taking care of our patients so it's those little things that we see when we see those changes in the monitor of our patient those little

things that happen in the room that you know maybe they're doing some reconstruction in your IR lab and your your MRI or something and and you've got to do a little workaround well that's not in your and we're gonna cover this a

little bit later with James riesen but that's not what you're used to and so your situational awareness changes and if you don't realize what's going on you may miss something and that something may be something very significant for

your patient and that's where those human factors come in where we have task overload under load communication factors that press on regardless how dangerous that can actually be so James

there are advantages of this modality one there's less radiation exposure for

the patient we receive about three millisieverts of background radiation every year with one PET scan a patient can get up to eight years worth of background radiation in just one skin the only exposure of radiation a patient

gets in a pet MRI is through the isotope pet MRI has a better disease characterization especially for areas in a Patou biliary region the pelvic areas and the kidneys information and the relationship between lesions and

adjacent tissue is better delineated with the pet MRI so it's easier to see which part is cancerous and which partners normal cells there are varying opinions and research studies are being done to make a determination if pet MRI

is a better modality than pet CTS well PET CT is a lower-cost skin has increased accessibility there are more PET scanners available and more more technologists are trained for this modality PET CT is a shorter skin there

are no contraindications for affairs implants pet CTS are preferred method for imaging the lungs of thoracic nodules and bone structures however with a pet MRI it's good for soft tissue organs such as the brain the muscle

delivered the kidneys the pancreas our GYN pelvic structures such as ovaries the uterus and cervix and also the prostate there are limitations of this skin one it is a much longer skin one whole body pet MRI can last at least

about an hour there are contraindications with certain implants due to the magnetic factor of the of this test and is not preferred for imaging air-filled structures because it can give off artifacts there

are weight limitations for our machine our machine holes can hold up to about 500 pounds of weight it is this our machine as smaller bore compared to the white board MRI the MRI whiteboy is about 70 centimeters in diameter

our pet MRI machine is only 60 centimeters in diameter in this picture the difference of the 10 centimeter difference doesn't seem much however if you put a patient in there and this is one of our coworkers

he is 270 pounds and 6 feet tall and the white board MRI his shoulders fit comfortably well inside it in the sky inside the scanner however in this pet MRI machine he said he did feel a little snug and a little tight inside

but you also have to take an account that we have to put coils on top of our patients that 10 centimeters does make a big difference the coils will help us give the good quality images that we like and I also have to note that we

have to put the head coil or the helmet on top of the patient's head to give good images of the brain the reason why the pet MRI scanner is smaller is because we have to make room for the pet detectors we try to make it bigger the

gradient coil on the radiofrequency coil have to be further away from the center of the magnet and that compromises the quality of our images so which patient

after having these two cases one in our institution and one at University of North Carolina Chapel Hill that we would then basically upsize our particles to

100 micron and we have not seen that and we're doing a second clinical study and I'm not seeing that as either we had about a 70% reduction in pain so if you look at our visual analog score out to six months and if you look at our

disability it actually paralleled this exactly which is pretty impressive considering mostly patients had bilateral knee pain so out to six months very good results 90% of patients were responders so two

out of our twenty patients did not really respond one patient didn't respond at his one-month follow-up but did respond at his three and six so I still consider him a clinical failure because we expect

these patients to respond by one month here's just an example of a baseline MRI before and after and you can see all that joint effusion there the white that decreases just even after a month how much it decreases and we looked at this

in terms of synovial thickness and distension and even on MRI you can object objectively count calculate synovitis scores and we calculated that they actually statistically decreased this is another patient on the left the

image shows diffuse white enhancement if you will of the synovium of the lining on the right it shows the fluid this is an image just of embolization and I show this image because it's really shocking and this is actually one of our nurses

who's enrolled in a clinical study is this is before this is all we did we embolized the medial aspect of the knee this is one month later 30 days in fact somebody just asked me this when I was in the booth over at the meeting across

the street and basically I said listen I don't know why this happened so quickly I have no idea we didn't tap renu-it into anything else if you look at this premium post it's pretty dramatic so clearly there's an inflammatory process

that we are arresting or stopping in such a short period of time so is there a future for this I don't know it may just we may just fall down and find out that there really is in a great future but so far we know it's at least

technically successful it's the results are positive in the short term long term we're not so sure yet we do need to better understand these risks and I think in my opinion in the long term it'll probably be really really good for

this 40 to 65 year old patient population who's not yet ready for knee replacement surgery this is the algorithm for our clinical study which were almost done enrolling right now it's a randomized control study against

placebo so it's two to one randomization which means one third of the patients actually get a sham procedure so we do an angiogram on their leg they're asleep they have no idea for embolizing they're genetical it arteries or not we wake

them up I think about the table and we follow them up if they're no better they're allowed to cross over and get the treatment the other 2/3 of the

I'm the FDG is have a radio pharmacy located on the second floor no New York State does allow nuclear medicine

technologist and nurses to inject the con the FDG isotope I know in other states one in particular is is New Jersey the the nurses are not allowed to inject isotope and the technologist has to do it also in addition certain

isotopes and certain scans the ducts have to inject the contrast like the the cervical Lin scintigraphy and some so my question has to do with discharge instructions so just like you give them that little card that they keep with

them so they trigger some radiation alarm and a bridge or on a highway do you give them discharge instructions about if there's small children at home that they're not sitting in their lap for extended period what kind of

instructions do you give on discharge after these patients so we when they come in coupled with the screening forms that they fill out we have some instructions attached to it and does that does have

the discharge instructions but we reiterate to them you know if they have small children or babies and pregnant women and just try to keep their distance for the next 12 to 24 hours just to until the really activity has

wear off so the FDG is like two hours almost for the half life FDA FDA has 60 minutes 116 minutes half life and usually by 12 hour by the 12 hour period they're mostly background radiation okay thank you

we had they have a written instruction like it's like a packet that we give into the market that we do to the patient and the patient have accessed to the web portal that they have and they can be the instructions from there

this is correct so betta bar is still investigational for the most part the only way you can build for it is two different scans you build for a pet and you build for our mr so you've got to get approval for both what you are not

going to get reimbursed for is the registration and that's where it gets a little bit challenging because then you need a radiologist who is both certified uncredentialed to read a pet and an mr so right now most institution bill it as

two different procedures so that's why you that's how we get the approvals just a little information on the side I went back to this case study because I forgot to tell you that in order for the PET CT to have as clear image as the pet MRI

the pet portion I mean the city portion and the pet city would have to be done diagnostically and that this would expose the patient to radiation three times that's why they prefer the pet MRI because yeah the reason why we do it if

we do it mostly for for for pediatrics and it's it and it's because of radiation because you know like our my team is saying you you are going to have this patient have constant follow-up so if you can reduce the amount of

radiation they have from a younger age as we all know it work in radiology DNA injuries occur when you're younger then more is more severe than than later our MRI the pet MRI injection they're all lined with lead and our MRI the pet

MRI room is actually lined with lead so we don't really have Needham let aprons we don't know we don't have wear aprons they are allowed to go to other appointments after they are pet MRI usually with the FDG most of the

radiation after the Tessa's finish is gone they're not more than what not more than radioactive than background radiation so they are are safe to be around people yes that's more for precautionary

measures yes no they go straight to the PACU so we our MRI table is detachable we have an area for where we keep our inpatient bay area we have a structured ready for them to go into right after the test and the

anesthesiologist and if they are Pediatrics the pediatric nurse is with them and they go straight to pack you do like probably like probably less than ten a week right now some weeks we are busy we do for how we do that much some

it varies like we'll do three or four but we are trying because the reimbursement that's one of the big issue our institution is actually eaten eating the cost for some of these to provide a patient with less radiation

especially or pediatric population we have one pet MRI machine for the whole institution three at the main campus we have two we have multiple and other regional sites so the yes

no less than 15 GFR except for the EU vist less than 30 then we notified the radiologists eeeh this is harder to so you this is the it's a linear contrast as opposed to the Catalan bettervest which is

macrocyclic so it's easier for the body to get rid of well there yes well they're only they're already getting dialysis so it's really not much of a harm yes we do patients on dialysis but we make sure the dialysis is done within

24 hours after receiving the contrast yes um sometimes you know you just have it to have it we don't require it for all the tests if you have it we have it we check if it's already in the chart we

acknowledge it you know we don't require for outpatient we don't require but in patients we do all right anything okay so Bernie pet/ct the scanning time for pet/ct is about 30 minutes to 45 minutes Patsy pet/ct is about 30 to 45 minutes

with the pet MRI sometimes they they order dedicated pet MRIs so that is a little longer you have to take note that we do a whole body scan whole body scans for even just for a regular MRI is at least an hour so we try to eliminate

just you know having them have to have to or point to different appointments and just one waiting room one waiting time so that cuts down the response for the patient themselves yes we do for adults it's 12 for the

whole body and then for the pet brain it's about 10 if I'm not mistaken and then plus or minus 10% and then the pediatric doses are cultured calculated base of their height and their weight and there are all protocol by a

radiologist because we have a lot of whole-body protocols we have the bone survey actually that's about 30 or 40 minutes and yes that's an hour and then we have longer whole body protocols diseases

specific and sometimes they try to depends on what the patient's diagnosis is we have whole body scans where they have to check the bone marrow and that needs to be from tips of the toes and tips of the fingers and that can be a

challenge especially if the patient is tall because that has to be in sequest sequestered and sequential patient and positioning is also a challenge alright thank you so much thank you thank you so much

[Applause]

turned the mic to my FA which she will be speaking about program implementation staff education requirements clinical work form and review some case studies

Thank You rose and good afternoon ladies and gentlemen I'm Rafael Donna I'm one of the regular genders at Memorial sloan-kettering I'd like to thank you now because I don't know later I might pass out because just a nervousness if

that possible let me know later okay I would like to acknowledge Pyrrha she's trying to leave now she's have to go back to New York thank you for helping us to make this presentation possible and Renee

he's here he's our clinical radiology director he's very supportive of us and thank you too Larisa Sanchez our nurse leader and Erika leer and are in for making this giving us opportunity to present before

I go into my part of the presentation let's say let's do a PET scan into to our MRI team you see the white floating areas over there let's pretend us the normal uptake from pet SDG but if we do pet MRI look what happens yay you see

their smiles it's very very vivid colors our team is very diverse you could see from all we come from all over different parts of the world they are awesome they help us give us this very good images that we're going to present today

the MS Casey pet MRI program planning and implementation took over a year the department have to hire dual modality artis who specifically trained for pet and MRI the cross training of our ends because we all MRI nurses we have to

cause cross train to nuclear medicine and pet department the construction of the radio pharmacy in the MRI suite and the development of the pet amar protocols in collaboration with the bio engineers physicists the radiology

leadership the attending radiologist the radiology leadership our ends and the artis also the compliance with the State Department of Health regulation guidelines very important part of this

do anesthesia for some of our cases mostly to our pediatric patients but we are also capable of doing it through the adults they need some anesthesia clearance patient is asked to be NPO

after midnight we have equipment available that are MRI compatible such as the monitors the IV pumps and the anesthesia ventilator machine when we set up the the patient inside the scanner we have to be wary of the lines

the table does move in and out during the test we don't want any of those IV tubing's get snagged we've done pretty good job in securing these lines usually by taping it on top of the coils after the pet MRI with

anesthesia is done they go to the PO 70 anesthesia care unit for recovery and I

new data of the Emmy trial that came out last year our ten-year results saying

that after ten years after ten years women who wanted to retain their uterus they looked at them in ten years three-quarters of those women were still very very satisfied and also were still able to retain their uterus so ten-year

data came out randomizing people for uterine artery embolization versus hysterectomy of the women who chose you to an artery embolization ten years later they were still very happy so I tell my patients that this is what you

should expect that you will have symptomatic improvement in 12 months around 85 to 95 percent of the patients are pretty happy there is a entry intervention rate it is not zero and it can be higher than ten

depending on what kind of Imogen is seen ahead of time and that we know that dysfunctional uterine bleed tend to do a little bit better than bulk type symptoms and that's partly because of subjective nature of that so this is one

of the patients that I treated when I was in in Virginia and Riverside and she's a former miss Brazil and she came to see us with what she also called reversed cycles like she would bleed more than she would not and she was

wearing depends and it took everything to just coach her out of the car to come inside to do a consultation because she was so afraid that if she got out she would be sitting in a pool of blood and she had an MRI showing what looked like

a eleven point seven centimeter fibroid she had embolization and that was her six month follow-up MRI to the right which looks like a very impressive result they don't all look this way which is why I save this image something

that looks like a normal uterus now I for the persons that I told to hold your high horse here is the time okay so what happens if I want to have a baby because these are the things you remember we're being ambassadors for this procedure we

need to be having the answers for the things that are our friends and family members are going to be asking us so if you want to have a baby I would say that the data that informs us as to what to do with you is still very weak but the

only randomized prospective trial that we have out there says that you should actually have myomectomy and a Cochrane review was also done and it still says that there's very low level evidence suggesting that myomectomy may be

associated with better fertility outcomes as opposed to UAE but more research is needed and we still require more research so at the very least what I have to do and now you feel compelled to do is to send my patients to see

someone who is a fertility specialist in consultation so we can make this decision together so if your poor surgical candidate if you have the gazillion fibroids and if you've had surgery before a hostile

abdomen and the patient says you know what dr. Newsome there's nothing that you can tell me ever to say that I'm going to have surgery then we're going to be doing something else that is not surgery okay the other thing that your

blasian it's well tolerated and folks with advanced pulmonary disease there's a prospective trial that showed that

there are pulmonary function does not really change after an ablation but the important part here is a lot of these folks who are not candidates for surgical resection have bad hearts a bad coronary disease and bad lungs to where

a lot of times that's actually their biggest risk not their small little lung cancer and you can see these two lines here the this is someone who dr. du Puy studied ablation and what happens if you recur and how your survival matches that

and turns out that if you recur and in if you don't actually a lot of times this file is very similar because these folks are such high risk for mortality outside or even their cancer so patient selection is really important for this

where do we use it primary metastatic lesions essentially once we feel that someone is not a good surgical candidate and they have maintained pulmonary function they have a reasonable chance for surviving a long

time we'll convert them to being an ablation candidate here's an example of a young woman who had a metastatic colorectal met that was treated with SPRT and it continued to grow and was avid so you can see the little nodule

and then the lower lobe and we paste the placement prone and we'd Vance a cryo plugs in this case of microwave probe into it and you turn off about three to five minutes and it's usually sufficient to burn it it cavitate s-- afterwards

which is expected but if you follow it over time the lesion looks like this and you say okay fine did it even work but if you do a PET scan you'll see that there's no actually activity in there and that's usually pretty definitive for

those small lesions like that about three centimeters is the most that will treat in a lot of the most attic patients but you can certainly go a little bit larger here's her follow-up actually two years

that had no recurrence so what do you do when you have something like this so this is encasing the entire left upper lobe this patient underwent radiation therapy had a low area of residual activity we followed it and it turns out

that ended up being positive on a biopsy for additional cancer so now we're playing cleanup which is that Salvage I mentioned earlier we actually fuse the PET scan with the on table procedural CT so we know which part of all that

consolidated lung to target we place our probes and this is what looks like afterwards it's a big hole this is what happens when you microwave a blade previously radiated tissue having said that this

was a young patient who had no other options and this is the only side of disease this is probably an okay complication for that patient to undergo so if you follow up with a PET scan three months later there's no residual

activity and that patient actually never recurred at that site so what about

thank you for joining me this morning as we talk about patient safety and risk management we're gonna touch on a number of different things but for starters can I see how many of bedside or procedural room nurses CTM our procedural room excellent okay all right okay all right

any leaders charge nurses directors awesome all right by chance are there any physicians in the crowd all right okay cool welcome thanks again for coming okay so just to note I have no financial or educational conflicts of

interests all right so today we're going to be talking about and discussing some key patient safety influencers in health care we're going to take a look at something that's called human factors engineering we're going to look at

educational and global human error reduction strategies and we're going to take a look at the just culture concept and its impact on patient safety Event Reporting so according to some statistics from this year for patient

safety week which was March 10th through March 16th so just a few days ago there are about that occur due to patient due to adverse events and 10 to 20% just to highlight a

few 10 to 20% during medical examiner cases they find that there have been some misdiagnosis during that so arriving at an accurate diagnosis is fundamental to the practice of medicine yet according to the 2015 Institute of

Medicine report most patients will experience at least one diagnostic err in their lifetime this report will also note that diagnostic errors contribute to about 10% of patient deaths and account for up

to 17% of adverse events during hospitalizations so currently we have about 41% of Americans who say that they've experienced a medical error either in their own care or that of a loved one or a friend and the National

Academy of Medicine and just a word about the National Academy of Medicine the IOM in July of 2015 changed their name to the National Academy of Medicine so this statistic comes post July of 2015 and they're

suggesting that 5% of US adults who seek care in outpatient settings experience a diagnostic error so that's the reason why we're here today so when we're

riesen comes to us and he talks about

some theories on why we make mistakes so and we're gonna cover these and then we're gonna cover the Swiss cheese model which many of you may be aware of so sorry slips tend to hurt current situations that are so routine that

they've become rote so an example of a slip could be selecting the wrong drug from a drop-down alright so again slips and lapses occur when the correct plan is made but executed incorrectly so we have that drop down of drugs but we just

select the wrong one that's a slip a lapse is generally not visible because it's reflective of a memory failure so for instance we may have a patient who forgets to take their medications or we may have a prescriber that forgets to

take a drug off of a med rec so those are examples of slips or lapses mistakes or judgment failures they're more subtle and they're complex than slips and these can go undetected for a period of time and they're often left to

a difference of opinion well I don't do it the same way that Mary does it who doesn't do it the same way that sue does it so those are mistakes and their knowledge base we know the right thing to do but because we have outside things

that are occurring situations that are occurring we may have to do some workarounds and those workarounds aren't always safe or we're gonna get in and this is part of the anatomy we're gonna get into the anatomy a little bit later

and often mistakes are rule-based so we know the rules we know what we're supposed to do but for factors that are out of our control we bypass those and that's when mistakes can happen active failure failures are highly visible

errors and we usually see these because they have immediate consequences and then the latent failures their processes that are under the radar they come from not following policies and there may be a good reason why we're not following

policies but oftentimes we hear that we've always done it that way and that means they're rooted in culture so that's where the justa culture comes into play all right Swiss cheese model so this is this is probably a graphic

that's very familiar to a lot of people but it does really it's it's at the basis of a patient safety air so organizations have defenses those are the slices of cheese now those defenses although we'd like them to be solid

they're oftentimes not they're filled with holes because of human factors the human condition those active and latent failures the slips lapses and mistakes that happen to all of us it's a part of us so often some of those defenses get

penetrated but then there's another defense that stops let's take for example identifying a patient so a patient comes in and maybe they're not english-speaking they may be

spanish-speaking and so we call their name and they answer the answer yes because it's close enough right it's close just close enough and they come up we don't check anything we don't check don't verify their name and their date

of birth we pass them on to our prep recovery room and then we're getting them ready because we have confidence that Jane at our front desk she doesn't make an error she always identifies the right patient so we have a high level of

confidence in Jane it's not a bad thing that's an OK Fay but here again we're not doing what we know is in our policy so it's rule-based and that we know is the right thing to do so it's knowledge base so it becomes a

mistake that we're not checking our patients identity and date of birth and that patient gets back to let's say the interventional room and boom we stop because now we're doing a timeout and we identify that we have the wrong patient

for our procedure and it stops but sometimes these heirs line up the holes line up and it's just one of those days and we end up with a patient safety event at the end so now we come to the

year old patient diagnosed with

glioblastoma lesion is located on the left frontal lobe this is done after radiation and surgery the image to your left is just a regular MRI with contrast gadolinium is the one used this time we always be the drum in the context of

choice is gadolinium in our institution you could notice the big size of the glioblastoma lesion onto the left frontal lobe of the patient as indicated in the round ring patient went for treat radiation and surgery look at the two

images to your right the one in the middle is done Pet MRI without the contrast take a note on the area where the lesion was before there is normal uptake but you don't notice any abnormal uptake and on to your right is post

treatment MRI is that those two are done the same day and with gadolinium the deletion the area where the the ring it is enhanced by the contrast but look at it there is no hypermetabolic uptake that means that the lesion is not viable

so the malignancy is not viable this time this scan is done to evaluate the effectiveness of the treatment it's a good sign before I go to the third case

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