Concern for The Joint Commission defined Sentinel Event is present when Air Kerma measured during a fluoroscopy procedure is >15 Gy. This lecture will address lessons learned (good, bad and ugly); and an assessment of what went right during interventional fluoroscopy cases with Air Kerma measurements >15 Gy.

Mr. Leuenberger is the Radiation Safety Officer at the Louis Stokes VAMC and a Certified Health Physicist. His experience also includes Medical Health Physicist with the Cleveland Clinic, past President of NOCHPS, and Health Physicist in environmental remediation. Ron is a graduate of Gannon University with a Master’s degree in Environmental Studies.