Some hospital patients accidentally exposed to radiation
The Health Information and Quality Authority (HIQA) has found that there has been an increase in the number of incidents whereby patients in hospitals are accidentally exposed to radiation.
The report provides an overview of the findings from these notifications throughout 2020 and shares learnings from the investigations of these incidents.
In 2020, HIQA received notifications of 76 significant events, an increase of 11% when compared with numbers for 2019. This is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.
The most common error reported to HIQA involved medical exposures to the wrong service user, which accounted for 34% of all notifications reported. Notifications from the modalities of interventional cardiology, mammography, and fluoroscopy were also received for the first time.
Human error was identified as the main cause in 58% of notifications received, however it was found that undertakings looked beyond the human factor and determined that other factors contributed to these errors in the vast majority of incidents.
John Tuffy, Regional Manager for Ionising Radiation, said: “In 2020, our inspections of medical exposure to ionising radiation found that the management of accidental and unintended exposures to ionising radiation was generally good; however, there is room for improvement in local incident management systems. We welcome the increase in reporting in 2020, as it potentially suggests a more open and positive patient safety culture. The increase in reporting is a positive indicator, particularly in the context of the unprecedented additional challenges faced by undertakings during the COVID-19 pandemic.”
Sean Egan, Head of Healthcare Regulation said “The overall findings of our report show medical exposures in the Irish setting may be considered safe for service users. HIQA will continue to build upon its programme to date to promote patient safety in relation to radiation protection and to improve the quality and safety of services for all. We hope that the areas for learning identified in this report, particularly around safety measures to enhance patient identification, will aid service providers in protecting patients against future preventable incidents of accidental or unintended exposure.”
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