ABSTRACT
We report an instance of microwave antenna breakage upon insertion through rigid costal cartilage and tip dislodgement during withdrawal of the antenna. Furthermore, we highlight antenna incompatibility with certain coaxial needles. Given the complexity and fragility of microwave antennas, it is not recommended to insert them through rigid tissue such as cartilage or calcified pleural plaques.
Subject(s)
Electrocoagulation/adverse effects , Foreign Bodies/etiology , Foreign Bodies/surgery , Lung Neoplasms/complications , Lung Neoplasms/surgery , Pleural Cavity/injuries , Pleural Cavity/surgery , Aged, 80 and over , Electrocoagulation/instrumentation , Foreign Bodies/diagnostic imaging , Humans , Male , Microwaves/therapeutic use , Pleural Cavity/diagnostic imaging , Radiography , Treatment OutcomeABSTRACT
PURPOSE: The aim of this article is to review a system that validates and documents the process of ensuring the correct patient, correct site and side, and correct procedure (commonly referred to as the 3 C's) within medical imaging. METHODS: A 4-step patient identification and procedure matching process was developed using health care and aviation models. The process was established in medical imaging departments after a successful interventional radiology pilot program. The success of the project was evaluated using compliance audit data, incident reporting data before and after the implementation of the process, and a staff satisfaction survey. RESULTS: There was 95% to 100% verification of site and side and 100% verification of correct patient, procedure, and consent. Correct patient data and side markers were present in 82% to 95% of cases. The number of incidents before and after the implementation of the 3 C's was difficult to assess because of a change in reporting systems and incident underreporting. More incidents are being reported, particularly "near misses." All near misses were related to incorrect patient identification stickers being placed on request forms. The majority of staff members surveyed found the process easy (55.8%), quick (47.7%), relevant (51.7%), and useful (60.9%). CONCLUSION: Although identification error is difficult to eliminate, practical initiatives can engender significant systems improvement in complex health care environments.
