Preventing Harm From Fluoroscopically Guided Interventional Procedures With a Risk-Based Analysis Approach.

Published on Sep 1, 2019in Journal of The American College of Radiology4.268
· DOI :10.1016/J.JACR.2019.02.047
Grace N. Justinvil1
Estimated H-index: 1
(National Patient Safety Foundation),
Edwin M. Leidholdt1
Estimated H-index: 1
+ 6 AuthorsJean M. Moran31
Estimated H-index: 31
(UM: University of Michigan)
Sources
Abstract
Abstract Purpose Fluoroscopically guided interventional (FGI) procedures often have lower complication rates compared with alternative surgical procedures, providing an option for patients with a high risk of perioperative mortality. Although severe radiation injuries are rare, patients receiving peak skin doses exceeding 3 Gy can suffer from radiation-induced tissue injuries, ranging from transient erythema to nonhealing wounds. As these iatrogenic injuries may manifest weeks to months postprocedure, proper diagnosis and timely medical intervention are less likely. Clinically, the lack of situational awareness for monitoring air kerma continues to be a challenge despite the recommendations of numerous organizations on ways to achieve fluoroscopy safety. For patient safety efforts, this study aimed to identify and mitigate systematic gaps associated with potentially high-radiation dose fluoroscopic procedures in US Department of Veterans Affairs (VA) and non-VA medical institutions. Methods In this study, a multi-institutional team utilized Healthcare Failure Mode and Effect Analysis (HFMEA) on an example implantable cardioverter defibrillator lead extraction procedure. Results With this approach, 29 interventions were devised and prioritized by feasibility, cost-effectiveness, and expected clinical impact. Five of the 29 interventions were recommended for immediate implementation or piloting. Conclusions This work demonstrates the application of formal risk-based analysis techniques in FGI procedures. These high priority interventions may be valuable for other facilities to consider when performing potentially high–radiation dose procedures and conducting risk-benefit analyses. Formal risk analysis techniques such as the HFMEA process are recommended for other facilities to use to improve safety for their high-risk procedures.
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References18
Newest
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Last. Ellen Yorke (MSK: Memorial Sloan Kettering Cancer Center)H-Index: 62
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200 CitationsSource
#2Kuo-Chung YangH-Index: 6
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With increasing numbers of percutaneous coronary intervention (PCI) and complex cardiac procedures, higher accumulated radiation dose in patient has been observed. We speculate cardiac catheter intervention induced radiation skin damage is no longer rare. To study the incidence of cardiac fluoroscopic intervention induced radiation ulcer. We retrospectively reviewed medical records of those who received cardiac fluoroscopic intervention in our hospital during 2012 to 2013 for any events of radia...
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Objectives This study sought to determine the efficacy of low rate fluoroscopy at 7.5 frames/s (FPS) versus conventional 15 FPS for reduction of operator and patient radiation dose during diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) via the transradial approach (TRA). Background TRA for cardiac catheterization is potentially associated with increased radiation exposure. Low rate fluoroscopy has the potential to reduce radiation exposure. Methods Patients und...
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#1Stephen Balter (CUMC: Columbia University Medical Center)H-Index: 20
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Iatrogenic radiation injuries are an accepted complication of therapeutic radiation therapy, however, they can also occur during fluoroscopic procedures. These are challenging wounds and are often misdiagnosed, leading to frustration for the patient and treating physicians. We reviewed 3 cases of severe fluoroscopic bums with ulceration, non healing wounds, and preoperative debilitating pain. The average number of fluoroscopy procedures was 2.7, with an average total fluoroscopy procedure time o...
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Background Fluoroscopy during ERCP has a linear relationship with radiation, carrying risk of exposure. Objective To determine patient, physician, and procedural factors affecting fluoroscopy duration. Design Prospective analysis of ERCPs with evaluation of patient, physician, and procedural variables. Setting Two tertiary-care hospitals. Patients Consecutive patients undergoing ERCP. Interventions ERCP. Main Outcome Measurements Variables associated with prolonged fluoroscopy duration. Results ...
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The clinical applications of fluoroscopy and MR imaging for interventional and diagnostic purposes are rapidly expanding, necessitating a renewed awareness of iatrogenic radiologic skin injuries. This article reviews the risk factors, clinical characteristics, and management strategies for imaging related skin injury relevant to radiologists. Skin injuries resulting from diagnostic imaging or radiologic interventions are rare complications that receive relatively little attention in the medical ...
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