One of my never-ending fears is that I forget something when going through the security check points in airports. I try to have a system for collecting my things after passing through the screen, i.e. first I retrieve my computer and other stuff, and then my bag and shoes, so I have less chance of leaving something behind. Apparently, this is not even a full-proof solution for everyone. Once I heard an airport announcement for someone at gate five to pick up his shoes.
When I am fit and ready to leave for a trip, there is less chance of forgetting something. However, if I am suffering from severe jet lag, which makes me feel like I am sleepwalking, and I am transferring somewhere overseas, e.g. from London Heathrow to Gatwick airport, I am surely more prone to forget something. I actually only forgot my laptop once, which is not a bad record given the many trips I make, and fortunately I found out in time. I was checking through Munich after teaching a class and was half asleep because of the time difference. I was relaxing in the airport lounge, ready to go to the gate. Fortunately something triggered my consciousness when picking up my computer bag finding it to be very light. I rushed back to security and yes, they had stored my computer securely and after identifying myself I was able to retrieve it, and hurry to the gate.
When dealing with medical information such as patient demographics and images, one cannot afford to suffer from jet lag, sleep deprivation or not being 100 percent fit. I know that it is hard if you get a call in the middle of the night to fix a study that was unidentified, rejected by the PACS, or not posted on a work list for whatever reason, but you have a responsibility to the patient to make sure you don’t forget anything. The best way to do this is to have a fixed rule or process in place that is easy to follow and to check the fix when you are fresh and bright in the morning.
When fixing things, also make sure that you use the right tools and know what you are doing. I often hear professionals using tools that they find for free on the Internet, which might not be validated or tested for use in a clinical environment. Now, there are many great free and open source utilities, many of them I use myself, but just make sure that when you use one of them, you ask around and/or do some testing with these prior to relying on them. Let me give you some examples of what I have seen in the field.
There are devices that create duplicate unique identifiers (UIDs). By definition a UID is supposed to be unique worldwide and used to uniquely identify studies, series, images, frame of references, etc. It is used to index the database, for storing and retrieving. Therefore, duplicate UID’s used for different entities undermines the UID system and creates major problems. If a device has a poor UID generator, one might need to replace and fix this UID. One solution I heard of is that some administrators take the UID and add a “.1” to the end of the UID string. This is very dangerous as this is not necessarily unique. The solution is to use a tool that creates a new UID, using its own “root.”
Another example is when one changes the image header with a utility that does not recalculate and update the number of bytes in a particular group. The problem is that early versions of DICOM had a so-called “group length” attribute in the header, which indicated how many bytes there are in a particular group such as the patient information group. These attributes have long been retired, and are rarely being created, however, some applications still create and/or use this information or just check the value, and, if incorrect, will reject the image or report an error.
Another example is the correction of incorrect overlay information, which is not uncommon for ultrasound images. If a technologist forgets to change the patient information when scanning a new patient, it is possible that the incorrect patient information is “burned in” as an overlay into the image data. A similar, but even more severe patient safety issue occurs when the Left/Right marker is on the wrong side of an X-ray.
In both cases, the pixel data has to be changed, assuming that an exam retake and/or recapture of the image is not possible. Many administrators simply use an overlay utility and put “XXXX” over the incorrect text or markers. This might appear correctly on a PACS viewing station, but when displaying on a different vendor workstation, Teleradiology, or web-based viewers these overlays might disappear leaving an incorrectly identified image. This is also an issue when migrating the images to another PACS vendor system as overlays are often not migrated. One should use a tool that eliminates and replaces the actual pixel values.
In conclusion, it is important to be alert and keep your eyes open and use the right tools when dealing with patient and image information.
Herman Oosterwijk, VP OTech Media