Evaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events

doi:10.1016/j.acra.2013.01.002

Academic Radiology

Volume 20, Issue 4, April 2013, Pages 457-462

https://doi.org/10.1016/j.acra.2013.01.002 Get rights and content

Rationale and Objectives

To address the risk of radiation injury during interventional procedures, the Joint Commission has defined prolonged fluoroscopy resulting in a cumulative skin dose of 15 Gy or more to a single field as a reviewable sentinel event. The goal of this work is to present a system for identifying potential fluoroscopic sentinel events (FSE) and describing common case characteristics.

Materials and Methods

Criteria based on fluoroscopic time (FT) > 150 minutes and reference air kerma (RAK) > 6 Gy were used to identify potential sentinel events. Case information including procedure type, number of procedures, and radiation dose parameters was recorded. Peak skin dose (PSD) was calculated by a medical physicist. Values were compared between procedure types and the relationship between FT, RAK, and PSD was evaluated.

Results

Between 2008 and 2011, 183 events exceeding the investigation criteria were identified in three interventional categories: cardiology (54%), neuroradiology (31%), and vascular (16%). The average number of procedures/patient was 1.7 ± 0.1, with the majority (59.6%) having undergone only one procedure. Most cases could be identified using the RAK criterion alone (96.7%). Based on the PSD/RAK ratio, a threshold RAK of 7.5 Gy would effectively identify all cases that would exceed 15 Gy in PSD.

Conclusion

Radiation delivered during interventional cases can place patients at risk of cutaneous radiation injury and potential sentinel events. Using appropriate thresholds to determine which cases require detailed investigation allows efficient utilization of department resources for identifying sentinel events.

Section snippets

Systematically Monitoring for Potential Sentinel Events

To properly identify sentinel events, a system must be used to identify potential high-dose cases. Although the Joint Commission does not explicitly indicate that fluoroscopic cases must be maintained in a database (3), accurate recording of cases is necessary to identify potential sentinel events. The goal of an identification mechanism is to identify all cases that may have surpassed the 15-Gy limit. To achieve this high sensitivity, investigations should be triggered by stricter threshold

Number and Type of Cases Identified

In the period included in the study, 183 high radiation dose cases qualifying as potential sentinel events were identified. Complete data for all cases were present in 81.4% of recorded cases, with one or more FT or RAK measurements missing from the remainder of cases (13.1% and 5.5%, respectively). The average total FT and RAK were 105 ± 40 minutes and 8.9 ± 1.2 Gy. The average physicist-calculated PSD was 8.6 ± 1.5 Gy.

Cases fell into three primary categories: cardiologic, neuroradiologic, and

Discussion

As defined by the Joint Commission, any fluoroscopic case that places a patient at unexpected risk of serious injury because of peak skin dose exceeding 15 Gy is a sentinel event. Both from a regulatory compliance and patient safety standpoint, awareness of this definition and the types of cases that are likely to result in fluoroscopic sentinel events is important. In this article, specific criteria (FT > 150 minutes or RAK > 6 Gy) were used to identify 183 high-dose cases that were possible

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Cited by (2)

Understanding and Using Fluoroscopic Dose Display Information
2015, Current Problems in Diagnostic Radiology
Citation Excerpt :
Although NCRP 168 provides guidelines for SRDL values, it also indicates that it may be appropriate to modify these values for specific patients or procedures. Adjustments could be based on experience or additional sources of published literature.18,19 To address radiation injuries in medical procedures, the Joint Commission created a reviewable sentinel event that addresses radiation overdose.4
Fluoroscopically guided procedures are an area of radiology in which radiation exposure to the patient is highly operator dependent. Modern fluoroscopy machines display a variety of information, including technique factors, field of view, operating geometry, exposure mode, fluoroscopic time, air kerma at the reference point (RAK), and air kerma area-product. However, the presentation of this information is highly vendor specific, and many users are unaware of how to interpret this information and use it to perform a study with the minimum necessary dose. A conceptual framework for understanding the radiation dose readout during a procedure is to compare it to the dashboard of an automobile, where the rate at which radiation is being applied (the RAK rate [mGy/min]) is the dose “speed” and the cumulative amount of radiation applied (cumulative RAK [mGy]) is the dose “odometer.” This analogy can be used as a starting point to improve knowledge of these parameters, including how RAK is measured, how RAK correlates with skin dose, and how parameters are displayed differently during fluoroscopy and fluorography. Awareness of these factors is critical to understanding how dose parameters translate to patient risk and the consequences of high-dose studies. With this increased awareness, physicians performing fluoroscopically guided procedures can understand how to use built-in features of the fluoroscopic equipment (pulse rate, beam filtration, and automatic exposure control) and fluoroscopic techniques (procedure planning, patient positioning, proper collimation, and magnification) to reduce patient radiation dose, thereby improving patient safety.
Novel X-ray imaging technology enables significant patient dose reduction in interventional cardiology while maintaining diagnostic image quality
2015, Catheterization and Cardiovascular Interventions

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Original investigationEvaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events

Rationale and Objectives

Materials and Methods

Results

Conclusion

Section snippets

Systematically Monitoring for Potential Sentinel Events

Number and Type of Cases Identified

Discussion

J Vasc Interv Radiol

J Vasc Interv Radiol

J Am Coll Radiol

J Am Coll Radiol

J Vasc Interv Radiol

J Vasc Surg

Am J Cardiol

J Vasc Interv Radiol

J Vasc Interv Radiol

J Am Coll Radiol

Original investigation
Evaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events