HIQA publishes first overview report on significant events of accidental or unintended medical exposures reported in 2019
The Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events arising from accidental or unintended medical exposures in 2019. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which 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 errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement for undertakings. Further potential learnings are included within the report.
John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required."
When reviewing the corrective measures applied by undertakings following the occurrence of a significant event, a varied approach to patient safety was found. While a frequent corrective measure was the re-education of staff; undertakings should consider other risk management strategies, such as simplifying or standardising procedures or the automation of processes to help prevent errors from reoccurring.
John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.”
It was noted that in many of the notifications submitted, there was an emphasis on the error of an individual or individuals involved in the process, rather than the evaluation of the system error that lead to such incidents.
John Tuffy has said “It is hoped that the key areas identified in this report will inform service providers of the types of issues that are common in diagnostic radiology and radiotherapy facilities but will also assist learning to prevent future preventable incidents occurring.”
Marty Whelan, Head of Communications & Stakeholder Engagement
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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 European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, 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.
- An 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.
- An 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.
- HIQA received notifications from computed tomography (CT), nuclear medicine, general radiography and radiotherapy services
- interventional cardiology and interventional radiology, which are both areas associated with potential high radiation doses did not submit notifications
- there was no reported significant events from the dental, DXA and mammography sectors. However, in these areas, the dose of radiation involved would fall below threshold for a significant event and therefore, low levels of reporting would be expected given the current criteria.