Evaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events

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 syste...

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Veröffentlicht in:Academic radiology 2013-04, Vol.20 (4), p.457-462
Hauptverfasser: Weinberg, Brent D., MD, PhD, Vance, Awais, MD, Arbique, Gary M., PhD, Guild, Jeffrey B., PhD, Anderson, Jon, PhD, Chason, David P., MD
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container_end_page 462
container_issue 4
container_start_page 457
container_title Academic radiology
container_volume 20
creator Weinberg, Brent D., MD, PhD
Vance, Awais, MD
Arbique, Gary M., PhD
Guild, Jeffrey B., PhD
Anderson, Jon, PhD
Chason, David P., MD
description 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.
doi_str_mv 10.1016/j.acra.2013.01.002
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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) &gt; 150 minutes and reference air kerma (RAK) &gt; 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.</description><identifier>ISSN: 1076-6332</identifier><identifier>EISSN: 1878-4046</identifier><identifier>DOI: 10.1016/j.acra.2013.01.002</identifier><identifier>PMID: 23498987</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>fluoroscopic time ; Fluoroscopy - adverse effects ; Humans ; peak skin dose ; Radiation Dosage ; Radiation Injuries - etiology ; radiation overdose ; Radiography, Interventional - adverse effects ; Radiology ; reference air kerma ; Sentinel event ; Sentinel Surveillance ; Skin - radiation effects</subject><ispartof>Academic radiology, 2013-04, Vol.20 (4), p.457-462</ispartof><rights>AUR</rights><rights>2013 AUR</rights><rights>Copyright © 2013 AUR. Published by Elsevier Inc. 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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) &gt; 150 minutes and reference air kerma (RAK) &gt; 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.</description><subject>fluoroscopic time</subject><subject>Fluoroscopy - adverse effects</subject><subject>Humans</subject><subject>peak skin dose</subject><subject>Radiation Dosage</subject><subject>Radiation Injuries - etiology</subject><subject>radiation overdose</subject><subject>Radiography, Interventional - adverse effects</subject><subject>Radiology</subject><subject>reference air kerma</subject><subject>Sentinel event</subject><subject>Sentinel Surveillance</subject><subject>Skin - radiation effects</subject><issn>1076-6332</issn><issn>1878-4046</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2013</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kdGL1DAQxoMo3nn6D_ggffSlvZmkbVIQQZY9PThQOe85pOlEsmabtWkX9r83ZU9BH5yXGcL3fUx-w9hrhAoB2-tdZexkKg4oKsAKgD9hl6ikKmuo26d5BtmWrRD8gr1IaQeATavEc3bBRd2pTslL9rA9mrCY2cexiK64CUucYrLx4G2xMYlS8XUxwbuTH78XJhVf4kzj7E34W3q_Po4Uiu0xT-kle-ZMSPTqsV-xh5vtt82n8u7zx9vNh7vS1ohziaaFBjuqHap2kJ1wwtgBsWuka6QVoFBIKWrFyVne90MvDQ4Omt61jUQQV-ztOfcwxZ8LpVnvfbIUghkpLkmjQKlqKTjPUn6W2rx0msjpw-T3ZjppBL3i1Du94tQrTg2oM85sevOYv_R7Gv5YfvPLgndnAeVfHj1NOllPo6XBT2RnPUT___z3_9ht8KO3JvygE6VdXKYx89OoE9eg79eDrvdEAbkEF78AlFya9Q</recordid><startdate>20130401</startdate><enddate>20130401</enddate><creator>Weinberg, Brent D., MD, PhD</creator><creator>Vance, Awais, MD</creator><creator>Arbique, Gary M., PhD</creator><creator>Guild, Jeffrey B., PhD</creator><creator>Anderson, Jon, PhD</creator><creator>Chason, David P., MD</creator><general>Elsevier Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>20130401</creationdate><title>Evaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events</title><author>Weinberg, Brent D., MD, PhD ; Vance, Awais, MD ; Arbique, Gary M., PhD ; Guild, Jeffrey B., PhD ; Anderson, Jon, PhD ; Chason, David P., MD</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c411t-1a60519e4f186d793f3acd11957f57c30813773482efc2bbdb7a1df05bf657103</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2013</creationdate><topic>fluoroscopic time</topic><topic>Fluoroscopy - adverse effects</topic><topic>Humans</topic><topic>peak skin dose</topic><topic>Radiation Dosage</topic><topic>Radiation Injuries - etiology</topic><topic>radiation overdose</topic><topic>Radiography, Interventional - adverse effects</topic><topic>Radiology</topic><topic>reference air kerma</topic><topic>Sentinel event</topic><topic>Sentinel Surveillance</topic><topic>Skin - radiation effects</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Weinberg, Brent D., MD, PhD</creatorcontrib><creatorcontrib>Vance, Awais, MD</creatorcontrib><creatorcontrib>Arbique, Gary M., PhD</creatorcontrib><creatorcontrib>Guild, Jeffrey B., PhD</creatorcontrib><creatorcontrib>Anderson, Jon, PhD</creatorcontrib><creatorcontrib>Chason, David P., MD</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Academic radiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Weinberg, Brent D., MD, PhD</au><au>Vance, Awais, MD</au><au>Arbique, Gary M., PhD</au><au>Guild, Jeffrey B., PhD</au><au>Anderson, Jon, PhD</au><au>Chason, David P., MD</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Evaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events</atitle><jtitle>Academic radiology</jtitle><addtitle>Acad Radiol</addtitle><date>2013-04-01</date><risdate>2013</risdate><volume>20</volume><issue>4</issue><spage>457</spage><epage>462</epage><pages>457-462</pages><issn>1076-6332</issn><eissn>1878-4046</eissn><abstract>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. 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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.</abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>23498987</pmid><doi>10.1016/j.acra.2013.01.002</doi><tpages>6</tpages></addata></record>
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subjects fluoroscopic time
Fluoroscopy - adverse effects
Humans
peak skin dose
Radiation Dosage
Radiation Injuries - etiology
radiation overdose
Radiography, Interventional - adverse effects
Radiology
reference air kerma
Sentinel event
Sentinel Surveillance
Skin - radiation effects
title Evaluation of Fluoroscopic Cases Qualifying as Potential Fluoroscopic Sentinel Events
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