Preventing wrong-site vertebroplasty procedures: An iterative quality improvement project

BACKGROUND AND PURPOSE: Wrong-site vertebroplasty is a known complication of image-guided procedures. Although rare, these errors have considerable clinical and medicolegal implications and are considered "never" events. This iterative quality improvement study set out to create and implement several new safeguard measures to ensure the prevention of wrong-site vertebroplasty procedures. MATERIALS AND METHODS: Iterative processes were enacted within a procedural practice of a neuroradiology division of a major academic institution. These focused on ensuring compliance of the primary outcome measure (obtaining and saving a fluoroscopy image that is marking the site(s) of interest with an overlying forceps) and process measure (requests that a CT and/or MRI image was inserted into the consult note, visually documenting the site(s) of interest). Because of the scarcity of wrong-site procedures, these were considered too rare to be useful for statistical evaluation. Balancing measures were put into place to monitor for unintended consequences: procedural radiation dosage, sedation time, and fluoroscopy time. RESULTS: Following a baseline period, three iterative quality improvement cycles occurred between October 1, 2025, and February 6, 2026. By the final phase, there was near perfect compliance with both obtaining pre-procedural fluoroscopy image and inserting an image into the consult note. Compliance with the saved pre-procedural fluoroscopy image was achieved, in part, due to initiation of a "second time-out" in which a technologist would remind the physician to obtain and save a fluoroscopy image. The balancing measures showed no significant change, and thus no unintended consequence, over the course of this project. CONCLUSIONS: Several measures can be easily implemented to serve as safeguards against a wrong-site vertebroplasty, but may require several iterations to ensure full compliance.