Dose Notifications and Alerts

 

  • It is now required that new CT scanners display CT Dose Notifications and Alerts. The notifications and alerts trigger a message to appear on the scanner when the exam will exceed pre-determined radiation dose.
    • When the notification message appears, the technologist has the option to enter a reason why the exam is exceeding the pre-determined radiation dose (e.g. large patient body habitus).
    • When the alert message appears, it is mandatory that a reason is given for why this exam will exceed the dose limit.
  • The intent of the notification and alert system is to ensure that each patient receives the minimum possible radiation dose. The message that appears on the scanner serves as a reminder to the technologist to ensure that each patient radiation dose is optimized.
  • An adverse event in CT is an occurrence that harms a patient or creates a risk of harm.
  • Scanning errors can include wrong-patient or wrong-protocol imaging, unintended repeat acquisition, excessive scan length, incorrect technical factors, incorrect contrast administration, or a missed dose-alert review.
    • The first priority after the technologist becomes aware of an error is to ensure patient safety. Stop the scan if it is in progress or correct the process when possible.
    • The patient should then be assessed, and the appropriate clinical team notified per policy.
  • After immediate needs are addressed, the event should be documented and reported through the facility’s incident or quality system.
    • As part of the safety program, an analysis of the event’s cause is likely to be conducted.
    • The review will assess protocol design, workflow, communication, training, equipment, and human factors as contributing factors to the error and use that information to prevent it from happening again.
  • CTDIvol and DLP are two dose measurements that can help identify unusual exposures.
  • A dose notification or alert is a scanner workflow tool that monitors exposure and can notify a technologist if the projected exposure exceeds predetermined thresholds. When this occurs, it is appropriate to review the scan parameters before proceeding.
    • An event report documents a potential patient-safety concern.
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