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Research ArticlePatient Safety
Open Access

Fluoroscopic Sentinel Events in Neuroendovascular Procedures: How to Screen, Prevent, and Address Occurrence

A.Z. Vance, B.D. Weinberg, G.M. Arbique, J.B. Guild, J.A. Anderson and D.P. Chason
American Journal of Neuroradiology August 2013, 34 (8) 1513-1515; DOI: https://doi.org/10.3174/ajnr.A3185
A.Z. Vance
aFrom the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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B.D. Weinberg
aFrom the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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G.M. Arbique
aFrom the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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J.B. Guild
aFrom the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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J.A. Anderson
aFrom the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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D.P. Chason
aFrom the Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.
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REFERENCES

  1. 1.↵
    1. Miller DL,
    2. Balter S,
    3. Cole PE,
    4. et al
    . Radiation doses in interventional radiology procedures: the RAD-IR study. Part II. Skin dose. J Vasc Interv Radiol 2003;14:977–90
    CrossRefPubMedWeb of Science
  2. 2.↵
    National Council on Radiation Protection and Measurements. Radiation Dose Management for Fluoroscopically-Guided Interventional Medical Procedures. Bethesda, Maryland: National Council on Radiation Protection and Measurements; 2010. NCRP Report No. 168
  3. 3.↵
    The Joint Commission. Radiation overdose as a reviewable sentinel event. http://www.jointcommission.org/assets/1/18/Radiation_Overdose.pdf. Accessed January 22, 2012
  4. 4.↵
    International Electrotechnical Commission. Medical Electrical Equipment-Part 2–43: Particular Requirements for the Safety and Essential Performance of X-Ray Equipment for Interventional Procedures. Geneva, Switzerland: International Electrotechnical Commission; 2000. IEC 60601-2-43 ed1.0
  5. 5.↵
    Code of Federal Regulations. Performance standards for ionizing radiation emitting products: Sec 1020.32 Fluoroscopic equipment. Title 21, Volume 8: Part 1020. Available at: http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=1020.32. Accessed January 22, 2012
  6. 6.↵
    1. Miller DL,
    2. Balter S,
    3. Cole PE,
    4. et al
    . Radiation doses in interventional radiology procedures: the RAD-IR study. Part I. Overall measures of dose. J Vasc Interv Radiol 2003;14:711–27
    CrossRefPubMedWeb of Science
  7. 7.↵
    1. Steele JR,
    2. Jones AK,
    3. Ninan EP
    . Establishing an interventional radiology patient radiation safety program. Radiographics 2012;32:277–87
    CrossRefPubMed
  8. 8.↵
    US Food and Drug Administration. Avoidance of serious x-ray-induced skin injuries to patients during fluoroscopically-guided procedures. September 9, 1994. http://www.fda.gov/downloads/RadiationEmittingProducts/RadiationEmittingProductsandProcedures/MedicalImaging/MedicalX-rays/ucm116677.pdf. Accessed January 25, 2012
  9. 9.↵
    1. Balter S,
    2. Hopewell JW,
    3. Miller DL,
    4. et al
    . Fluoroscopically guided interventional procedures: a review of radiation effects on patients' skin and hair. Radiology 2010;254:326–41
    CrossRefPubMedWeb of Science
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American Journal of Neuroradiology: 34 (8)
American Journal of Neuroradiology
Vol. 34, Issue 8
1 Aug 2013
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Fluoroscopic Sentinel Events in Neuroendovascular Procedures: How to Screen, Prevent, and Address Occurrence
A.Z. Vance, B.D. Weinberg, G.M. Arbique, J.B. Guild, J.A. Anderson, D.P. Chason
American Journal of Neuroradiology Aug 2013, 34 (8) 1513-1515; DOI: 10.3174/ajnr.A3185

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Fluoroscopic Sentinel Events in Neuroendovascular Procedures: How to Screen, Prevent, and Address Occurrence
A.Z. Vance, B.D. Weinberg, G.M. Arbique, J.B. Guild, J.A. Anderson, D.P. Chason
American Journal of Neuroradiology Aug 2013, 34 (8) 1513-1515; DOI: 10.3174/ajnr.A3185
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  • Article
    • Abstract
    • ABBREVIATIONS:
    • What Is a Fluoroscopic Sentinel Event?
    • Screening for Potential Fluoroscopic Sentinel Events
    • Minimizing Radiation-Induced Skin Injury
    • Fluoroscopic Sentinel Event Investigations
    • Conclusions
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