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?

Reference:

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

Picture:

http://www.brighamandwomens.org/publicaffairs/Images/Missed%20delayed%20diagnosis.jpg