The Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2021. This report provides an overview of the findings from these notifications and shares learnings from the investigations of these incidents.



In 2021, HIQA received notifications of 86 incidents, an increase of 26% compared with numbers for 2019. This is a small number relative to the total number of medical exposures taking place, which can conservatively be estimated at over three million exposures a year. While the overall number of notifications increased, it was highlighted that some facilities with high levels of activity did not submit any notifications during 2021. Low rates of reporting may suggest a lack of reporting rather than a lack of incidents. HIQA encourages facilities to review their reporting pathways to ensure a strong culture of radiation safety awareness and associated learning.



The most common location for a reported incident to occur was in CT, with 59% of notifications in 2021. Furthermore, the most common error reported to HIQA remains as medical exposures to the wrong service user, which accounted for 26% of all notifications reported.



Human error was identified as the main cause in 57% of notifications received. HIQA noted a reliance on people-focused corrective actions which might be discouraging individuals from reporting incidents when they happen. To support a progressive reporting culture, HIQA encourages facilities to make system-focused changes as they have shown to be more effective in reducing the reoccurrence of incidents.



In 2021, over half of the initial notification reports were submitted outside the 3 working day timeframe required by HIQA. Although most facilities faced ongoing challenges in 2021, with the ongoing COVID-19 pandemic and the national public sector cyber-attack, facilities should ensure that systems and processes are in place to consistently report incidents within the specified timeframes.



Agnella Craig, Regional Manager for Ionising Radiation, said, “Overall, we found that the management of accidental and unintended exposures to ionising radiation was generally good, and service users should feel safe when attending for medical exposures. We will continue to build upon the programme to promote patient safety in relation to radiation protection and to improve the quality and safety of services for all.”



John Tuffy, Head of Healthcare, said, “The increase in reporting is a strong indicator of facilities having a more positive and open patient safety culture. However, we hope to see more facilities embedding learning identified in this report to help prevent future possible incidents of accidental or unintended exposure.”

Ends.

Further information:

Marty Whelan, Head of Communications & Stakeholder Engagement

085 8055202, mwhelan@hiqa.ie



Notes to Editor:

• In 2019, new regulations were put in place to transpose into Irish law the EU Council Basic Safety Standards (BSS) Directive of 2013. Under the law, HIQA is the competent authority for patient protection in relation to medical exposure to ionising radiation in Ireland.
• Medical exposure to ionising radiation is when radiation is used as part of diagnosis such as a dental X-ray or CT scan or the use of radiotherapy as part of cancer treatment at a hospital. It also includes radiation received for medical research purposes and radiation received by carers and comforters while attending a patient.
• Computed tomography (CT) is a technique for imaging the body in sections or slices using specialised computers and imaging equipment. An alternative name for CT is computer-aided tomography or CAT scan.
• A facility (undertaking) is a person or body who has the legal responsibility for carrying out, or engaging others to carry out, a medical radiological practice, or the practical aspects of a medical radiological procedure, as defined by the regulations.
• A facility (undertaking) carrying out medical exposures to ionising radiation must notify HIQA of the occurrence of a significant event.
• Incidents involving medical exposures that are deemed to be above or below an acceptable threshold and have the potential to cause harm are called significant events. These incidents can occur from either diagnostic, interventional or therapeutic procedures when medical ionising radiation administered to the service user was greater or different to what was intended.
• Notifications:
  • HIQA received notifications from computed tomography (CT), nuclear medicine, general radiography, fluoroscopy, mammography, interventional cardiology and radiotherapy services.
  • Interventional cardiology and interventional radiology, are both areas associated with the potential for high radiation doses. Notifications were received from interventional cardiology facilities, however none were received from interventional radiology facilities.
  • There was no reported significant events from the dental or DXA services. However, in these areas, the dose of radiation involved would generally fall below the threshold for a significant event and therefore, low levels of reporting would be expected given the current criteria.