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Health watchdog notified of 68 'significant events' of accidental or unintended exposure to ionising radiation

The majority of these events related to CT scans and involved relatively low dosses of radiation.

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THE HEALTH WATCHDOG was notified of 68 significant events arising from accidental or unintended medical exposure to ionising radiation last year, according to a new report.

The Health Information and Quality Authority (Hiqa) has today published an overview report on the lessons learned from notifications of events which can involve patients being sent for a scan they did not need. 

In 2019, Hiqa received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities. The most commonly reported type of event (31%) was when an incorrect patient was exposed to radiation.

The report states that 68% of these events related to CT scans, 19% related to radiotherapy, 10% related to nuclear medicine and 3% related to general radiology. The majority of these events were of relatively low doses of radiation and posed little risk to patients.

Hiqa said the number 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 errors, it said, 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. 

John Tuffy, Regional Manager for Ionising Radiation, said the overall findings of the 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,” he said.

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“However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required.”

It was noted in the report 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.

Tuffy said that while these events are 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.”

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