Managing uncertainty in complex interventional fluoroscopic procedures.

Area of Science:

• Medical Physics
• Radiology
• Patient Safety

Background:

• Interventional fluoroscopic procedures carry a risk of patient skin burns from high radiation doses.
• Two sentinel events were indicated due to high air kerma readings during procedures.

Purpose of the Study:

• To analyze patient safety concerns during interventional cardiology fluoroscopic procedures.
• To identify lessons learned and propose a systems-based approach to improve radiation safety.

Main Methods:

• Dose reconstruction using machine output measurements to assess air kerma readings.
• Review of existing radiation safety program and implemented additional controls.

Main Results:

• Air kerma readings were approximately four times higher than expected, indicating potential for burns.
• The existing radiation safety program successfully identified equipment issues before patient injury.
• No patient injury or sentinel event occurred due to timely detection and intervention.

Conclusions:

• A comprehensive radiation safety program is crucial for detecting equipment malfunctions during interventional fluoroscopy.
• Implementing additional controls, including quality checks and mandatory dose tracking, further enhances patient safety.
• A systems-based approach and continuous improvement are vital for reducing radiation risks in complex procedures.