Since January 2019, the Health Information and Quality Authority (HIQA) has been the competent authority for regulating medical exposure to ionising radiation in Ireland and receives incident notifications of significant events arising from accidental or unintended medical exposures. As part of its role, HIQA is responsible for sharing lessons learned from significant events.
HIQA has published an overview report on the lessons learned from notifications of significant incident events in Ireland 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.
A varied approach to patient safety was evident on review of the corrective measures applied following the occurrence of a significant event. High efficacy corrective measures such as forcing functions, which can eliminate risk, were evident. However, in some cases, the corrective measures put in place to prevent recurrence were limited to low efficacy strategies such as re-education of staff. Undertakings should consider the risk management strategies applied to incident investigations and corrective measures to ensure they are robust and help prevent errors from reoccurring rather than punish.
Overall, many of the investigation reports received by HIQA were comprehensive and showed systems based approaches to reviewing incidents. Some, however, focused on human error in isolation, without consideration of human error as a symptom of system weaknesses. Undertakings should ensure a just culture is in place where individuals feel free to report errors, assured that the response will focus on what happened, rather than who failed. This was not always evident in reports received by HIQA.
Finally, it is noted that radiation incidents reported to HIQA in 2019 have involved relatively low radiation doses with limited risk to service users. The findings in this report indicate that overall the use of radiation in medicine in Ireland is generally quite safe for patients. However, radiation incidents have been reported internationally with severe detrimental effects to service users. The potential for such serious adverse events highlights the need for ongoing vigilance in relation to radiation protection and the necessity of reporting and learning frameworks. It is hoped that areas of improvement noted in this report would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland.