Sources of Error in Interventional Radiology: How, Why, and When

Area of Science:

• Medical Imaging
• Interventional Radiology
• Patient Safety

Background:

• Interventional radiology (IR) is an imaging-based specialty with unique error considerations.
• Data on medical errors in IR are less abundant compared to surgical and medical fields.
• Understanding error sources is crucial for improving patient safety in IR procedures.

Purpose of the Study:

• To provide a comprehensive overview of error sources in interventional radiology.
• To develop a taxonomy of errors in IR.
• To supplement existing IR literature with insights from other medical specialties and the World Health Organization.

Main Methods:

• Literature review of available IR error data.
• Inclusion of lessons learned from surgical and medical specialties.
• Consideration of individual risks (e.g., cognitive bias) and system-level factors.
• Development of a taxonomy categorizing errors by operator, patient, team, and environment.

Main Results:

• Identified unique error considerations in IR due to its procedural and imaging-based nature.
• Highlighted the scarcity of dedicated error literature within IR.
• Proposed a multi-factorial taxonomy for understanding errors in IR.

Conclusions:

• A structured approach to understanding errors in interventional radiology is needed.
• Addressing individual and system-level factors is essential for error reduction in IR.
• Further research and reporting of errors in IR are warranted to enhance patient safety.