Lessons learned from events declared to the ASN related to interventional radiology and having occurred during radiation-based acts

Based on an analysis of events declared to the ASN and inspection observations performed in the field of interventional radiology, this report outlines that the majority of these events could have been avoided and that they result from a lack of culture in radiation protection, notably an unawareness of doses delivered to patients or received by practitioners, and of risks related to exposure to ionizing radiations. The report notably outlines that events are related to a lack of staff and means in the field of patient and personnel radiation protection, an underdeveloped risk management and radiation protection implementation, lacks in the management of delivered or received doses and absence of approaches of professional practice assessment, operator insufficient education, and weaknesses in the management of subcontracted operations. Recommendations are made related to needs in medical radio-physics, identification of acts and patients at risk and definition of patient follow-up modalities, the implementation of an approach of professional practice assessment, the storage of dosimetric data, the improvement of operator technical education, the control of subcontracted operations, and the anticipation of technical and organisational changes