The document discusses complications from interventional medical procedures and the need to improve reporting and prevention of complications. It notes that complications are underreported and increasing over time. It calls for developing standardized definitions of reportable complications, protocol-based practice, and classifying complications to better understand them and take preventative measures. The overall goal is to help doctors avoid harming patients in accordance with the principle of "first, do no harm".

1. Dr Ashok Jadon,
MD, DNB, MNAMS, FIPP
Chief Consultant Anaesthesia & Pain Relief Service,
Tata Motors Hospital,
Jamshedpur

3.  “Primum non nocicerum” — firstly, do no
harm
 Complications are biggest deterrent to
achieve this.

4. 1. To avoid,
2. To identify and prevent
collateral damage,
3. To manage and treat if
occurred.

5.  Hospital employees recognize and report only
one out of seven errors,
 In some cases, person assumed someone else
would report the episode or
 It is thought that it was so common that it did
not need to be reported, or
 “events were isolated incidents unlikely to
recur”
 cause ; fault in reporting system;

6.  Over the years, the number of interventional
procedures performed & the number of
malpractice claims has increased dramatically
 Prescribed protocols have not been followed or
 correct techniques have not been used..
 There is no standardized body of knowledge
required for the field..
 Individual physicians must police themselves as
to their competency and qualifications for safe
practice…
 Unfortunately, it appears that often this is not the
case..

7.  We must classify event unanimously
 develop a list of “reportable events”
 We should have “detailed, unambiguous
instructions on the types of events that
should be reported”
 We must do Protocol based practice
◦ Protocol War
◦ Which protocol
◦ We have to decide

8.  Black swan event
 Pre procedure precautions…
 Physician attitude towards patients
 Repeated errors during conduct of
interventional procedures
 Effects of medical malpractice of healthcare
delivery
 Fear of reporting

9.  Stellate ganglion Block; convulsion due to
vertebral artery injection
 Huntoon suggests that, the deep cervical vessels
anterior to the transverse process may be
involved in causing seizure during SGB.
 Modified Technique for Stellate Ganglion Block
avoids/minimizes the chance of vascular injury

10.  un-diagnosed that’s why unreported
◦ Continuous updating & prevention of complication:
 Which group this complication belongs to?
◦ Classifying Complications of Interventional
Procedures

11.  Complications are increasing
 Complications are under reported
 How to improve reporting
 How to reduce complications
 Need for intervention …..??????