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Related Experiment Video

Updated: May 23, 2026

Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine
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Nine-Grid Area Division Method: A New Ideal Bone Puncture Region for Percutaneous Vertebroplasty in Lumbar Spine

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Preventing wrong-site vertebroplasty procedures: An iterative quality improvement project.

John C Benson1, Carrie M Carr2, Ian T Mark2

  • 1From the Department of Radiology (J.C.B., C.M.C., I.T.M., J.T.V., G.B.L., P.P.M., T.A.B., C.J.D., M.L.K., D.P.S., D.K.K., M.P.O., B.A.J.-T.), Mayo Clinic, Rochester, MN 55905, United States and Harvard TH Chan School of Public Health (C.K.), Boston, Massachusetts, United States Benson.John3@mayo.edu.

AJNR. American Journal of Neuroradiology
|May 21, 2026
PubMed
Summary

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This summary is machine-generated.

Implementing new safeguards, including a "second time-out," significantly reduced wrong-site vertebroplasty errors. This quality improvement initiative enhanced procedural safety in neuroradiology without adverse effects.

Area of Science:

  • Medical Imaging
  • Neurosurgery
  • Quality Improvement

Background:

  • Wrong-site vertebroplasty is a rare but serious complication of image-guided procedures.
  • These errors have significant clinical and medicolegal consequences, classified as 'never' events.
  • Preventing wrong-site procedures is a critical patient safety goal.

Purpose of the Study:

  • To develop and implement safeguard measures to prevent wrong-site vertebroplasty.
  • To improve compliance with pre-procedural site marking and documentation.
  • To evaluate the effectiveness of iterative quality improvement cycles.

Main Methods:

  • Iterative quality improvement cycles were implemented in a neuroradiology practice.
  • Focus on ensuring pre-procedural fluoroscopy imaging with site marking (forceps) and documentation (CT/MRI in consult note).

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Last Updated: May 23, 2026

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  • Balancing measures (radiation dose, sedation time, fluoroscopy time) monitored for unintended consequences.

    • Main Results:

    • Near-perfect compliance achieved for pre-procedural imaging and documentation after iterative cycles.
    • A "second time-out" procedure contributed to compliance with saved fluoroscopy images.
    • No significant changes observed in balancing measures, indicating no unintended consequences.

    Conclusions:

    • Easily implementable safeguard measures can effectively prevent wrong-site vertebroplasty.
    • Iterative implementation and refinement are key to achieving full compliance.
    • Quality improvement initiatives are vital for enhancing patient safety in image-guided procedures.