Dealing with complications in interventional radiology

Abstract

It is widely accepted that most misadventures, which lead to harm have not occurred because of a single individual but rather due to a failure of process that results in healthcare workers making mistakes. This failure of process and the pervasiveness of adverse events is just as prevalent in Interventional Radiology (IR) as it is in other specialities. The true prevalence and prevailing aetiology of complications in IR are not exactly known as there is a paucity of investigative literature into this area; especially when compared with other more established disciplines such as Surgery. Some IR procedures have a higher risk profile than others. However, published data suggests that many adverse events in IR are preventable (55-84%) and frequently involve a device related complication such as improper usage or malfunction. This article aims to discuss factors that contribute to complications in IR along with tools and strategies for dealing with them to achieve optimal patient outcomes.

Fig. 1

WHO Safety Checklist [46]

Fig. 2

‘Five why’s- a practical example for how to determine the root cause of an adverse event. Source- The 'Five Whys' Analysis—Health Innovation West of England (healthinnowest.net)

Fig. 3

Suggestions for conducting a debrief [46, 48]

Fig. 4

a External iliac artery rupture post angioplasty (shown by white arrow). b External iliac artery following deployment of a covered stent to seal the site of rupture

Fig. 5

a, b Axial and sagittal CT images for patient who deteriorated on the ward post RIG insertion. White arrows show the gastrostomy tube traversing collapsed transverse colon

Fig. 6

Sample of standard after care instructions documented post gastrostomy:

Fig. 7

Recommended documentation labels for gastrotomy patients to warn of potential life-threatening complications [47]