Today, 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 2020. This report provides an overview of the findings from these notifications 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.

HIQA encourages undertakings to continue their efforts to improve the level of reporting. This can be achieved by promoting an organisational culture that empowers, encourages and supports staff to report and communicate issues of concern relating to radiation safety. Weaknesses in communication and justification processes were identified as recurring contributory factors in notifications received in 2020. Some of the issues identified relating to miscommunication or ineffective communication are demonstrated in the case studies included in HIQA’s report.

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.”

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.
• 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.
• 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 for interventional cardiology, however none were received for interventional radiology.
  • 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 threshold for a significant event and therefore, low levels of reporting would be expected given the current criteria.
  • Justification of incidents mean that the benefits of carrying out a procedure exposing a patient to ionising radiation must outweigh the risks.