Avoiding and Managing Error in Interventional Radiology Practice: Tips and Tools

Abstract

While there are limited data on error in interventional radiology (IR), the literature so far indicates that many errors in IR are potentially preventable. Yet, understanding the sources for error and implementing effective countermeasures can be challenging. Traditional methods for reducing error such as increased vigilance and new policies may be effective but can also contribute to an “error cycle.” A hierarchy of effectiveness for patient safety interventions is outlined, and the characteristics of “high-reliability” organizations in other “high-risk” industries are examined for clues that could be implemented in IR. The evidence behind team error reduction strategies such as checklists is considered along with individual approaches such as “slowing down when you should.” However, error in medicine is inevitable, and this article also seeks to outline an evidence-based approach to managing the psychological impact of being involved in medical error as a physician.

Adverse Events Self-Reporting in Radiology:A New Avenue for Excellence

“…Current evidence supports the use of pre-procedure checklists because they undoubtedly prevent adverse events. 2 Unfortunately, even in the best environment and with the most skilled operators, vascular interventional radiology cannot be 100% free of adverse events.…”

Typology, Severity, and Outcomes of Adverse Events Related to Angiographic Equipment—A Ten-Year Analysis of the FDA MAUDE Database

“…The proportion of adverse events in healthcare which are preventable ranges between 25 and 84%. 4,5,7 These occurrences could potentially be minimized by optimization, standardization, and updating techniques and equipment, 8,9 but this is contingent on identifying the true source of the issue. Post-market surveillance of medical devices is an essential component of quality improvement, 10 and it is mandatory in many regions, including in the United States and European Union.…”

“…8,12 VIR has additional risks due to its wide scope of practice. 9 Recent publications have highlighted a need to increase the understanding of adverse events within VIR. 8,13 There are several publications on the topic of patient and staff radiation exposure during angiography, 12,[14][15][16] but there is no available literature exploring malfunction and failure of this technology.…”

Interventional radiology in gynecology and obstetric practice: Safety issues

“…Literature in IR indicates that the majority of errors in IR are preventable. 46 IR procedures place the team in circumstances comparable to those experienced in operating theaters (persistent stress, operator tiredness, team inexperience) that can lead to mistakes: this explains the need to enhance patient safety measures through larger standardization of procedures and enlarged quality of care in IR procedures. Moreover, in addition to the most commonly recognized errors in medicine, some errors are specific to IR and can potentially occur at any time during the patient's stay in the angiographic suite.…”