NEW DEFINITIONS FOR RADIATION INCIDENTS
The enactment of law / regulations in England ie IR(ME)R 2017 resulted in new and amended requirements for radiation incidents, affecting both healthcare providers and CQC. The wording and definitions relating to radiation incidents changed, with ‘much greater than intended’ (MGTI) replaced with ‘significant accidental or unintended exposure’ (SAUE).
Key findings in 2018/19 The use of diagnostic imaging and nuclear medicine has continued to grow. In 2018/19, 43 million diagnostic imaging examinations were carried out on NHS patients in England, of which almost 30 million used ionising radiation. Activity across all types of imaging grew by just under 2% compared with the previous year.
Statutory notifications of errors in England between 1 April 2018 to 31 March 2019 received a total of 1,009 notifications during the year, which was comparable with the previous year (969). Although notifications relate to incidents where there is risk of harm, the majority do not result in harm to patients.
Diagnostic imaging (English hospitals)
- 796 notifications – an increase of 4% over the previous year. These comprised 79% of all notifications received in both 2017/18 and 2018/19.
- The diagnostic sub-modality with the highest proportion of notifications was computed tomography (CT).
- The most common type of error is still when the wrong patient receives an exposure, with 50% of all diagnostic imaging errors resulting from referrers failing to refer the right patient or operators failing to actively identify their patients.
Review of audits were also part of a drive to maintain a supportive culture for staff in the imaging department in the UK. They were designed to ensure that radiographic staff comply with local procedures, for example in relation to use of ‘Hello My Name Is’, making ID enquiries, data management, IR(ME)R authorisation, patient property, manual handling, infection control and information given to patients following their attendance. A senior colleague audited a different sample of staff each month.
The resulting initiatives included developing a ‘quality before speed’ mission statement to support the established ‘pause and check’ recommended by the Society of Radiographers. Although not in place for long, we heard that early feedback from staff in the department showed that the audit had been welcomed, supported good practice and is working well.
Example of improving engagement with pause and check
A provider had seen a number of incidents where operators had failed to formally identify patients or make final checks of exposure factors. In response, they used a new approach to ensure that staff were more engaged with the ‘pause and check’ initiative. As well as writing a reflective statement, the approach required staff to fill in a blank copy of the ‘pause and check’ poster after an incident. Example of action to limit distractions A provider identified that distraction was a factor in a number of incident investigations. Its actions to address this included:
· the radiographer scanning in CT wearing a tabard, as nurses do when dispensing drugs, which signals they must not be distracted during scanning
· removing telephones in the reviewing areas (apart from one for emergencies) and moving to an area where calls can be taken without distraction
· limiting the CT viewing area to essential staff only.
Example of diagnostic imaging error
During an inspection, we observed radiographers in a newly-installed diagnostic radiology room, which had been in use for a few months. Although the radiographers were highly experienced and were able to demonstrate knowledge of the local protocols, we found the defaults from the manufacturers were still in place in the room, which did not reflect the exposure charts or even the protocols used in the identical adjacent room.
Although the radiographers were comfortable in amending the factors to those required for all patients, this disconnection leaves the opportunity for error.