PT  - JOURNAL ARTICLE
AU  - A.Z. Vance
AU  - B.D. Weinberg
AU  - G.M. Arbique
AU  - J.B. Guild
AU  - J.A. Anderson
AU  - D.P. Chason
TI  - Fluoroscopic Sentinel Events in Neuroendovascular Procedures: How to Screen, Prevent, and Address Occurrence
AID  - 10.3174/ajnr.A3185
DP  - 2013 Aug 01
TA  - American Journal of Neuroradiology
PG  - 1513--1515
VI  - 34
IP  - 8
4099  - http://www.ajnr.org/content/34/8/1513.short
4100  - http://www.ajnr.org/content/34/8/1513.full
SO  - Am. J. Neuroradiol.2013 Aug 01; 34
AB  - SUMMARY: Radiation-induced skin injury during fluoroscopic procedures has been recently addressed by The Joint Commission, which defined prolonged fluoroscopy resulting in a cumulative peak skin dose of ≥15 Gy to a single field as a sentinel event (FSE). Neuroendovascular procedures can be associated with a high radiation skin dose and present risks such as potential FSEs. Managing these risks is the responsibility of the interventional neuroradiologist. In this review, we discuss hospital policies needed for screening and preventing FSEs, methods for minimizing radiation-induced skin injury, and actions necessary to address potential FSEs once they have occurred. FSEfluoroscopic sentinel eventFTfluoroscopy timeKa,rreference air kermaPKAkerma-area productRCAroot cause analysisTJCThe Joint Commission