Recommendations for radiographers and radiation therapists drawn from an analysis of errors on Australian Radiation Incident Registers

A Longitudinal Evaluation of Computed Tomography Radiation Incidents Within a Multisite NHS Trust

OBJECTIVES

This single-center review explores trends in computed tomography "radiation incidents" and suggests strategies for improvement.

METHOD

A retrospective mixed-methods approach was used in this longitudinal evaluation of radiation incidents within a multisite NHS Trust in northern England. DATIX was interrogated at the Trust level to identify all records linked to radiation incident in computed tomography departments between January 1, 2015, and December 31, 2018.

RESULTS

During the 4-year review period, 159,596 exams were performed at the Trust and a total of 133 incidents were recorded. This comprised 42.1% (n = 56) of radiation incidents, 43.6% (n = 58) of near-miss incidents, and 14.3% (n = 19) of repeat scans due to extravasation of contrast. The reported radiation incident rate was 0.08%. These data suggest an approximation of 1 incident per thousand cases. Most incidents were investigated using a "system approach," and the reports highlighted the relevant action that had been taken to try and prevent recurrence of the incident. Qualitative data collected from the root cause analysis minutes demonstrated themes related to the contributory factors, incident analysis performed, and overall learning.

CONCLUSIONS

Computed tomography departments need to focus on a system approach instead of the "person approach" to identify areas where efficiencies can be implemented. Staff should feel open to discuss system inefficiencies that they experience and may highlight problems the management is unaware of. The reporting of all types of incidents, including near misses, should be encouraged, to foster an open culture and to expand learning.

Patient safety is everyone's business

This editorial addresses the importance of incident reporting, checklists and a just culture to patient safety.

Building a learning culture and prevention of error - to near miss or not

This editorial provides an insight into learning and prevention of error through near miss event reporting.

Recommendations for radiographers and radiation therapists drawn from an analysis of errors on Australian Radiation Incident Registers

Introduction

The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) collect reported incidents for inclusion in the Australian Radiation Incident Register (ARIR), a database of radiation incident reports that occur within Australia. While the information on previous radiation incidents is available, there is little information on the lessons that can be learned from those past incidents to help prevent the same errors reoccurring. The aims of the study were to investigate what radiation incident registers are publicly available in Australia and to utilise the information contained within the ARIR and any other state or territory radiation protection authority registers to make recommendations for radiographers and radiation therapists to prevent future adverse events.

Methods

A search was conducted to locate what radiation incident registers within Australia were available to the public. All adverse events from 2003 to 2014 were compiled into a spreadsheet for analysis. An error‐type classification taxonomy was used to classify the adverse events. Conclusions were drawn from the determined causes to make recommendations to change work practices in an attempt to prevent similar adverse events reoccurring.

Results

Incident registers were located from New South Wales, South Australia, Tasmania, Victoria and Western Australia. Radiography represented 76% (243) of the adverse events. A vast majority of the incidents were a failure to comply with time‐out protocols (77%, 248).

Conclusion

There are several radiation adverse event registers publicly available to utilise in Australia. All departments need to adopt and strictly adhere to time‐out protocols. This in conjunction with the other recommendations in this article has the potential to dramatically reduce radiation adverse events.