title: Evaluation of fluoroscopic cases qualifying as potential fluoroscopic sentinel events.
abstract: OBJECTIVE
  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.
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
authors.forename: Brent D
authors.initials: BD
authors.lastname: Weinberg
authors.forename: Awais
authors.initials: A
authors.lastname: Vance
authors.forename: Gary M
authors.initials: GM
authors.lastname: Arbique
authors.forename: Jeffrey B
authors.initials: JB
authors.lastname: Guild
authors.forename: Jon
authors.initials: J
authors.lastname: Anderson
authors.forename: David P
authors.initials: DP
authors.lastname: Chason
mesh_terms: D005471:Fluoroscopy / Q000009:adverse effects*; D006801:Humans; D011829:Radiation Dosage; D011832:Radiation Injuries / Q000209:etiology*; D015641:Radiography, Interventional / Q000009:adverse effects*; D018571:Sentinel Surveillance; D012867:Skin / Q000528:radiation effects