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DH publishes list of Adverse Events that should not occur

5 September, 2012
Ticking boxes in a list

The Department of Health has published a document which summarises a range of adverse events that can be avoided through appropriate availability of Interventional Radiology (IR).

In order that IR services are delivered equitably and consistently, the DH is asking organisations to ensure that processes are in place that will prevent harm to patients and should any Adverse Events listed occur, that they are reported and investigated.

In a letter to the Society, Professor Erika Denton FRCP, FRCR, National Clinical Director for Imaging at the DH, wrote: "The need for networked IR services exists across the country, and although this is an area where change is gathering pace, inequalities remain.

"We are keen that all IR departments and staff be made aware of this list and that due recognition is given to the risks described so that appropriate action can be taken to mitigate against them."

The list of scenarios is as follows:

  • High risk pregnancies should be delivered in hospitals with IR services who should be involved in the pre-delivery planning.
  • No patient should undergo laparotomy for lower GI bleeding from any cause where embolisation may be appropriate without a referral to interventional radiology.
  • No patient should undergo surgery for non-variceal upper GI bleeding without first undergoing endoscopic treatment, and if this fails or is inappropriate, interventional radiology.
  • No patient with sepsis secondary to obstructed kidneys should wait longer than three hours for a drainage procedure such as nephrostomy.
  • No severely injured patient should die of haemorrhage from pelvic trauma because of a lack of early imaging and referral for interventional radiology.
  • No patient with a traumatic aortic dissection should have open surgery without a referral to interventional radiology for consideration of endovascular repair.
  • No patient should have open surgical repair of a GI variceal haemorrhage which is refractory to all other treatments without a referral to interventional radiology for transjugular intrahepatic portosystemic shunting (TIPS).
  • No patient with symptomatic fibroids should undergo hysterectomy without being informed about all possible options including Uterine Artery Embolisation.

 

The document can be downloaded here.

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