Table 1 Categories of contributing factors in root cause analysis [21]
From: Dealing with complications in interventional radiology
Category | Examples |
|---|---|
Human | Primary operator inexperience Inappropriate case selection Imaging misinterpretation Deviation from instructions for use (IFU) or locally agreed protocols Failure of open disclosure Delayed recognition of clinical signs and symptoms |
Technical | Challenging, technically difficult case Omission or error in the procedure |
System | Unreliable access to IR suite Lack of robust on-call arrangements Poor access to inpatient beds Excessive caseload Limited access to anaesthetic support |
Education | Poor Training Poor supervision of less qualified members of staff |
Patient | Comorbidities ASA grade Non-compliance Refusal to consent to treatment |
Device | Device malfunction Deviation from IFU (incorrect usage, or use outside the scope of IFU) |
Medication | Side effect Error in drug administration |