Managing Uncertainty in Complex Interventional Fluoroscopic Procedures

There was a concern for potential patient skin burns indicated by air kerma as recorded by fluoroscopy equipment during two interventional fluoroscopic procedures. Two sentinel events as defined by The Joint Commission were indicated. Dose reconstruction based on measurements of machine output showed the air kerma readings were high by approximately a factor of four and no patient injury or sentinel event occurred. The radiation safety program in effect at the time of the incidents allowed discovery of equipment problems before a serious patient injury occurred, but additional controls have been implemented as a result, including quality control checks performed by cardiology, additional training, a database for tracking equipment maintenance, and mandatory entry of patient dose into electronic health records with follow-up orders automatically generated by the electronic health records. Most unexpected injuries are a result of multiple failures, but there are also multiple opportunities to prevent the injury. This paper provides a comprehensive look at patient safety concerns during two interventional cardiology fluoroscopic procedures and offers ways to further reduce risks to patients. It focuses on lessons learned and a systems-based approach to improving and promoting radiation safety during complex interventional fluoroscopic procedures.