The Health Information and Quality Authority (HIQA) has published its annual overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures to ionising radiation in 2021.

In 2021, HIQA received notifications of 86 incidents, an increase of 26% compared with numbers for 2019. This is a small number relative to the total number of medical exposures taking place, which can conservatively be estimated at over three million exposures a year.

While the overall number of notifications increased, it was highlighted that some facilities with high levels of activity did not submit any notifications during 2021.

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Low rates of reporting may suggest a lack of reporting rather than a lack of incidents. HIQA encourages facilities to review their reporting pathways to ensure a strong culture of radiation safety awareness and associated learning.

The most common location for a reported incident to occur was in CT, with 59% of notifications in 2021.

Furthermore, the most common error reported to HIQA remains as medical exposures to the wrong service user, which accounted for 26% of all notifications reported.

Human error was identified as the main cause in 57% of notifications received. HIQA noted a reliance on people-focused corrective actions which might be discouraging individuals from reporting incidents when they happen.

To support a progressive reporting culture, HIQA encourages facilities to make system-focused changes as they have shown to be more effective in reducing the reoccurrence of incidents.

In 2021, over half of the initial notification reports were submitted outside the three-working-day timeframe required by HIQA.

Although most facilities faced ongoing challenges in 2021, with the ongoing COVID-19 pandemic and the national public sector cyber-attack, facilities should ensure that systems and processes are in place to consistently report incidents within the specified timeframes.

Agnella Craig, regional manager for ionising radiation, said: “Overall, we found that the management of accidental and unintended exposures to ionising radiation was generally good, and service users should feel safe when attending for medical exposures.

“We will continue to build upon the programme to promote patient safety in relation to radiation protection and to improve the quality and safety of services for all.”

John Tuffy, head of healthcare, said: “The increase in reporting is a strong indicator of facilities having a more positive and open patient safety culture.

“However, we hope to see more facilities embedding learning identified in this report to help prevent future possible incidents of accidental or unintended exposure.”

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