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Royal College of Radiologists - Duty of candour webinar
Patient-Safety-Learning posted a calendar event in Community Calendar
untilThe Faculty of Clinical Radiology has developed guidance on the duty of candour with the aim of providing radiologists with guidance and real-world examples on the implementation of the duty of candour. The document recognises the unique circumstances faced by radiologists and all who work in imaging. It is not possible to provide guidance for every situation, but the aim is to provide an approach which will help colleagues navigate an unfamiliar process in the best possible way for our patients and the professionals who care for them. The Royal College of Radiologists is hosting a webinar to discuss this new guidance and answer any queries. Please submit any questions in advance to guidance@rcr.ac.uk by Friday 24th June to ensure we are able to answer as many as possible. Register for the webinar- Posted
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Professor Ted Baker, CQC’s Chief Inspector of Hospitals, said:“It is important that organisations learn from incidents and take action to mitigate any risks when patients are exposed to ionising radiation from x-rays, radiotherapy or radiopharmaceuticals as part of their diagnosis or treatment." “The number of errors involving patients is small in the context of the many millions of procedures undertaken each year involving radiation. That said, in too many cases errors happen as a result of inadequate checks, poor communication, or because of a simple failure follow procedures around radiation protection." The report includes recommended actions that providers can take to improve compliance with the regulations and the quality and safety of care for patients. It also shares examples of good practice to help leaders and healthcare professionals identify where they can make improvements in their own services.- Posted
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This editorial by Dr Michael Farquhar, published in Anaesthesia, explains the importance of taking breaks while on shift and ensuring a good sleep between shifts and the inextricable link between sleep and patient safety.- Posted
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Clinical radiology UK workforce census report 2018
Claire Cox posted an article in Safe staffing levels
Key findings from the Clinical Radiology UK Workforce Census Report 2018 include: Three quarters of radiology clinical directors say they do not have enough radiology consultants to deliver safe and effective patient care. NHS hospitals spent £165m last year on outsourcing, overtime and locums to cover radiologist work, £49m more than in 2017 and three times what was spent in 2014. The amount spent on outsourcing would pay for 1,887 full-time radiologists, which would more than pay to cover the current shortfall of 1,104 consultants. Only one in five UK trusts and health boards has enough interventional radiologists to run a safe 24/7 service to perform urgent procedures . England has seen an increase in its full-time radiologist workforce; however, consultant numbers in Scotland, Wales and Northern Ireland are flatlining.- Posted
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Key findings The investigation identified that there: are multiple opportunities for error in the processes used to communicate unexpected findings are many steps that have to be completed successfully before the patient is informed is variance in how clinicians receive findings and how they acknowledge receipt of them.- Posted
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Further reading HIQA: Annual report of accidental or unintended exposures to ionising radiation in 2019 CQC reports on safe use of radiation in healthcare settings (19 December 2019)- Posted
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Northern Trust radiologist review finds 66 discrepancies
Patient Safety Learning posted a news article in News
A review of the work of a former locum consultant radiologist in the Northern Trust has identified major discrepancies in 66 images. The trust has concluded a review of 13,030 scans and x-rays. The review was launched in June after the General Medical Council raised concerns about the locum consultant radiologist's work. The highest level of hospital investigation will be carried out into the cases of 17 patients. More than 9,000 patients were contacted as part of the review. The review identified six images at level one - a major discrepancy where errors or omissions in reporting could have had an immediate and significant clinical impact for the patients concerned. A further 60 images were level two - a major discrepancy with a probable clinical impact. "Most of the images categorised as having Level 1 and Level 2 discrepancies are CT scans but some are MRI scans, chest x-rays and other x-rays," said the trust's medical director, Seamus O'Reilly. "That detailed clinical assessment, which has resulted in 69 patients being called back, was to determine whether any clinical harm occurred as a result of the discrepancies found in the lookback review," "I can confirm that following careful consideration, the clinical assessment group has determined that 17 patients should now be part of a Level 3 Serious Adverse Incident (SAI) review." Read full story Source: BBC News, 13 October 2021- Posted
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76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). This figure represents an 11% increase on the total reported in 2019. HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. 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. In its 2019 report — its first such publication — HIQA expressed hope that the areas of improvement it identified "would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland." Despite this, eight more accidental exposure incidents were recorded in 2020 than in the previous year. Human error was identified as the main cause of accidental exposure in 58% of the incidents, however, HIQA determined that other factors likely contributed to these. Some 34% of the incidents involved the wrong patient being exposed to ionising radiation. HIQA said these exposures occurred at varying points along the medical exposure pathway. It stressed that the number of unintended exposure to ionising radiation incidents last year was small compared with the total number of procedures carried out, estimated to be in the region of three million. Read full story Source: Irish Examiner, 15 September 2021- Posted
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A review into the work of a locum consultant radiologist has so far identified "major discrepancies" affecting 12 cases. A full lookback review of 13,030 radiology images was launched last month. The doctor worked at hospitals run by the Northern Health Trust between July 2019 and February 2020. The review steering group chair said it was "images in levels one and two that we are most concerned about". "To date there are 12 level ones and twos [approximately 0.5% of the total number reviewed]," said Dr Seamus O'Reilly, the Northern Trust medical director. "Most of these concern CT scans where inaccurate initial reading of the scans could, or is likely to, have had an impact on the patient's clinical treatment and outcome." More than 9,000 patients have been contacted as part of the review, which is looking at radiology images taken in Antrim Area, Causeway, Whiteabbey and Mid Ulster Hospitals as well as the Ballymena Health and Care Centre. Read full story Source: BBC News, 28 July 2021- Posted
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