October 3, 2008

Adverse Events in Radiology: Definition

A 68-year-old man, with diabetes and hypertension, went for a chest CT for a suspicious abnormality seen on a previous chest x-ray. He developed acute dyspnea, wheezing and hypotension after administration of IV contrast material. He passed away after extensive resuscitation effort.

What are adverse events in radiology?
  • Events in which a patient suffers unexpected harm +
  • Due to diagnostic imaging study or intervention +
  • Unrelated to patient's underlying medical condition 
Examples of adverse events:
  • Unintended retention of foreign object in patient
  • Fall
  • Medication error
  • Intervention on wrong body part, wrong side
  • Wrong intervention performed
  • Contamination of drugs, devices or biologics
What is "sentinel event"?
= Adverse events causing death or serious physical or psychologic injury

The above scenario illustrated a rare adverse event that could happen in any radiology department. It is a 'sentinel' adverse event since it brought about death to the case example. What and how to respond to the event?

Kruska JB, et al. Managing an acute adverse event in a radiology department. Radiographics 2008 (September 2008)

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