BSIR Announces Safety Advisory and Resources Regarding Adverse Events

March 27, 2015—The British Society of Interventional Radiology (BSIR) advised that the United Kingdom National Health Service (NHS) has recently received notification about a serious incident involving the inadvertent injection of chlorhexidine during angiography that occurred in an acute NHS Trust facility. This event, and the learning following its investigation, has been the subject of a safety video, “The Human Factor” released through YouTube. The video was made by the Trust, the patient, and a human-factors specialist from the aviation industry whose wife died during a procedure in 2005 and who now advises NHS facilities on the human factors in health care. 

BSIR stated that its members should consider whether such events could happen in their own departments. BSIR members are encouraged to submit relevant cases to READ (login required), the Radiology Events and Discrepancies newsletter, via the Royal College of Radiologists website, www.rcr.ac.uk.

The BSIR noted that the forthcoming issue of READ will be revisiting the patient safety film, “The System,” which is available on the BSIR website. BSIR members were closely involved in its production, and it details relevant learning cases. The purpose of the film was to provide realistic possible patient experiences and events to produce a worst-case scenario outcome. It is hoped that this can be used as a teaching model by interventional radiology teams to maximize patient safety.

BSIR members are requested to watch the video and bring it to the attention of other staff in their department, especially given that it is not an isolated incident, and similar events have occurred with inadvertent injection of glue and thrombin. Interventional radiologists should consider whether their departments are prepared for procedures to prevent and respond to similar events, stated BSIR.