The “Black Swan” in Interventional Radiology: Evaluation of Unexpected Events And Consequences

Learning Objectives: Black Swan events are unexpected highly impactful events that deviate from the norm with significant consequence on patient outcomes {1}. We aim to provide examples of unpredictable events that may occur during interventional radiology (IR) procedures, including procedural complications, device failures, and patient reactions. We provide strategies to enhance situational awareness, adaptive decision making, risk management, and debriefing to manage these events during procedures to enhance patient safety.

Background: In IR, procedures are oftentimes routine and without significant complications. Black Swan events are unexpected events that introduce complexity to rather straightforward procedures. These include patient variable anatomy, sudden hardware malfunction, and unanticipated physiologic responses by the patient {2}. These events are unpredictable and significantly impact procedural success, patient safety, and institutional policies.

Clinical Findings/Procedure Details: Black Swan events are often identified retrospectively in IR. Significant events with major consequences in patient health outcomes include unpredictable variation in patient anatomy, which imparts uncertainty to a routine procedure. Sudden severe procedural complications such as spontaneous vessel rupture or perforation during routine vascular access or life-threatening hemorrhage from routine catheter manipulation are uncommon but significantly impact patient outcomes. Device failures such as fracture of catheters, stents, or other tools necessitate immediate retrieval. Imaging system malfunctions impair catheter visualization during crucial procedural moments. Unanticipated patient reactions to contrast agents and other medications warrant immediate attention.

Conclusion and/or Teaching Points: Simulation exercises of uncommon but consequential events such as procedural complications, equipment failure, and patient physiologic reaction prepare staff when these events occur. Building resilience and promoting an environment of flexibility, situational awareness, and leadership is critical to manage crises. Risk management strategies are invaluable to recognize early warning signs and implement contingencies for complications. Team debriefing is perhaps the most important as it identifies areas warranting improvement and highlight aspects that were executed well {3}. While Black Swan events in IR are uncommon, preparing for the unexpected through simulations, resilience, and risk management can mitigate their impact, ultimately enhancing patient safety and procedural success.