Use of Barium Sulfate Contrast During Videofluoroscopic
Members have reported new or newly enforced Joint Commission
accreditation standards regarding the storage and use of barium
during the videofluoroscopic swallowing study (VFSS). Some reported
- Barium is considered a medication and must be treated as such
and kept under lock and key.
- The amount and type of barium used during the study must be
- SLPs must have established competencies in the use and
storage of barium.
Joint Commission Clarification of MM 4.10
MM 4.10: "All prescriptions or medication orders are
reviewed for appropriateness." (Joint Commission, 2004, p.
The following clarification was published in the June 2005 issue
Joint Commission Perspectives
(Vol. 25, Issue 6):
- Contrast media, [including barium contrast used during VFSS],
are considered a medication.
- Review of administration of barium by a pharmacist, while not
required, is a recommended safety step.
- The organization must adopt clinical practice guidelines or
approved screening tools to address the safe. administration of
barium. In hospitals, guidelines or screening tools must be
approved by the medical staff or pharmacy.
- Only trained, designated personnel can retrieve medications
- The appropriateness of using barium must be reviewed by a
qualified health care professional.
- Quality control procedures must be set up to prevent
- If needed, a pharmacist should be on-call.
- A quality control review of previous records in which
administration of barium was done without prior pharmacy review
should be done to identify any problems.
Ways in which facilities are handling these requirements (as
reported by members):
- Ensure the organization has identified an SLP who is authorized to access medication storage areas where barium may be stored.
- Barium is kept under lock and key.
- Radiology techs have the key and will unlock the cabinet to
get the Ba before the procedure or at the request of the SLP; in
some facilities, the SLP has a key and access to the stored
- Documenting amount of barium and, in some cases, the lot
number for the barium.
- Radiology techs write a note indicating that the procedure
was completed and how much barium was used.
- SLPs document the ratio of barium to food or liquid presented
and the exact amount given.
- All containers that have barium mixed into the food or liquid
must be clearly labeled.
SLPs' reports of how Joint Commission surveyors have
- "We were just surveyed last week. This issue was not
even mentioned as far as I know."
- "Our inpatient hospital just recently had a Joint
Commission survey. We "heard" and therefore implemented
the use of barium under lock and key. We did not hear, nor were
we asked about exact tracking of use or competencies in the use
- "We are reportedly required by Joint Commission to keep
the barium under lock and key, but I have not heard of the other
requirements you mention."
- "Jars of powdered barium sulfate that we use for our
studies were moved out of the rooms where we conduct fluoroscopy
to be stored in a locked closet. Now, when we want to prepare our
materials for a VSE we have to find a radiology tech with a key
to the closet so that we can get the barium we need."
- "We have been asked (or required) to record barium lot
numbers for both inpatient and outpatient MBSs. We document them
in our reports."
- One facility recently passed a Joint Commission survey by
keeping barium under lock and key and having the techs indicate
the amount of barium used during the procedure.
Facts About Barium Contrast
Barium Sulfate Safety Issues and Patient Protection
by Karen Brown, CCC-SLP):
- Barium sulfate is the most commonly used contrast material
for the videofluoroscopic swallowing study (Tamm and Kortsik,
- When administered orally, barium sulfate produces high
diagnostic yield with low risk of adverse events (Ansell,
- Barium sulfate is an insoluble salt and is almost completely
- Sources of complications include:
- Aspiration of large quantities of barium
- Complications reported in the literature come from the
amounts of barium used for GI studies (Voloudaki, et al,
2003). The amount of barium used for the VFSS is much
- While there have been reports of complications and even
death with aspiration of large amounts of barium (Gray, et
al, 1989), problems associated with ingestion of barium are
very rare (Tamm & Kortsik, 1999).
- Even in patients who have aspirated large quantities of
barium, the long-term prognosis after treatment has been
found to be "excellent due to the inert character of
barium sulfate" (Tamm & Kortsik, 1999).
- Problems that may cause intestinal stasis (e.g., bowel
References and Resources
Ansell, G. (1987). Alimentary tract. In G. Ansell & R.A.
Complications in diagnostic imaging
(2nd ed.), (pp. 218-246). Oxford: Blackwell Scientific.
Buschman, D.L., (1991).
Barium sulfate bronchography: Report of a complication
Erickson, L.M., Shaw, D., & MacDonald, F.R. (1979).
Prolonged barium retention in the lung following bronchography.
Gray, C., Sivaloganathan, S., & Simpkins, K.C. (1989).
Aspiration of high-density contrast medium causing acute pulmonary
inflammation - Report of two fatal cases in elderly women with
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Joint Commission. (2004).
Comprehensive Accreditation Manual for Hospitals: The Official
Oakbrook Terrace, IL: Author.)
Rasley, A., Logemann, J.A., Kahrilas, P.J., Rademaker, A.W.,
Pauloski, B.R., & Dodds, W.J., (1993).
Prevention of barium aspiration during videofluoroscopic swallowing
American Journal of Reontgenology, 160
Skucas, J. (2000). Contrast media. In R.M. Gore & M.S.
Textbook of gastrointestinal radiology
(2nd ed.), (pp. 2-14). Philadelphia: W. B. Saunders.
Tamm, I., & Kortsik, C. (1999).
Severe barium sulfate aspiration into the lung: Clinical
presentation, prognosis and therapy
Valoudaki, A., Ergazakis, N., & Gourtsoyiannis, N. (2003).
Late changes in barium sulfate aspiration: HRCT features
European Radiology, 13
Whiting, J. (2003). Aspiration of barium. (Letter to the
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