Sources of Error in Interventional Radiology: How, Why, and When

Abstract

This article aims to provide an overview of the sources for error in interventional radiology (IR). Being both a procedure and an imaging-based specialty, IR has unique considerations as to how error can occur. However, compared to the surgical and medical literature, data on error in IR are lacking. The available IR literature is reviewed but supplemented with lessons from other specialties and the World Health Organization. Individual risks such as cognitive bias as well as system-level factors are also considered in order to generate a taxonomy for error in IR that includes the operator, patient, team, and environment.

VIP Patients in Interventional Radiology: Do Some Patients Deserve “Better” Care?

“…VIPs often receive greater access to resources and attention from healthcare professionals, and yet, paradoxically, their care often inadvertently deviates from standard practice, which may confer poorer outcomes. 1,[4][5][6][7][8]10,15 The "spotlight" that accompanies high-profile VIPs or the pressure of caring for an influential patient can incite self-doubt that destabilizes our trained judgment and abilities. 8 This makes it easy to worry we are "not doing enough," and to overinvestigate or intervene on an issue in effort not to miss anything, as a result.…”

“…3,16 A contrasting phenomenon also occurs, wherein providers forgo tests or procedures that otherwise could have provided key information to save a patient time or discomfort. 7,10,15,16 When a healthcare professional presents as a patient, this pressure to skip over preliminary tests in effort to navigate the system more quickly may be even greater. 1,18 This tendency has a potential for critical error and serious consequences.…”

“…1,8 When this influence causes undue deviation in clinicians' trained judgment and in standards of care, the outcome is not always superior for the VIP or for the system; this is termed the "VIP syndrome." 5,9,10 There are some potential positive effects of VIP care. The current medical system can be rather byzantine and difficult to navigate, and VIPs may be able to circumvent unnecessary roadblocks.…”

“…1,5,6,11 Despite this, VIP patient care poses many practical and ethical challenges, such as complicating the allocation of finite resources and threatening the quality of care both for VIPs and non-VIPs. 1,3,10 Ultimately, VIP care is not necessarily wrong to engage in, but there is potential for it to be if doing so compromises patient care. Although this is a complex medical issue that interventional radiologists (IRs) are likely to encounter, most existing discussions are not specific to IR, and there is a lack of specialty-focused guidance for approaching these cases.…”

Interventional radiology in gynecology and obstetric practice: Safety issues

“… 44 , 47 Factors leading to error rarely occur in isolation and reflect a combination of events, including judgment errors, vigilance/memory failure, lack of technical competence, and communication breakdown. 49 …”