A nationwide investigation of radiation therapy event reporting-and-learning systems: Can standards be improved?

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.