A survey of incidents in radiology and nuclear medicine in the West of Scotland.
Data on 606 incidents in radiology and nuclear medicine departments reported to a central health physics service have been analysed and causes reviewed. 85% of incidents in radiology departments and 37% in nuclear medicine were overexposures of patients. 80% of these resulted from human error or procedural failure, and of these 32% were mistakes by the referrer. Other incidents in nuclear medicine were contamination events (49%) and failure in management of radioactive materials (10%). Effective doses for patient overexposures covered a broad range with those for CT being 1 mSv and above, while those for other radiology examinations were mostly less than 2 mSv. Reporting of patient overexposure incidents in radiology has increased by four-fold in recent years. The average numbers reported during the last 3 years were 91 per year in radiology and 12 per year in nuclear medicine, for hospitals with a population base of 2.8 million. Incident investigations demonstrated the importance of robust procedures and defences to identify mistakes that could lead to incidents. The central incident reporting and investigation system has raised the awareness of staff about the type of mistakes which could lead to incidents and promoted the introduction of recommended actions to reduce these risks.
Martin
C J
CJ
Health Physics, West House, Gartnavel Royal Hospital, Glasgow, UK.
D002983:Clinical Competence / Q000592:standards; D004307:Dose-Response Relationship, Radiation; D004781:Environmental Exposure / Q000009:adverse effects / Q000706:statistics & numerical data*; D006293:Health Promotion / Q000379:methods; D006306:Health Surveys; D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D009683:Nuclear Medicine / Q000706:statistics & numerical data; D016273:Occupational Exposure / Q000009:adverse effects / Q000706:statistics & numerical data; D010808:Physical Examination / Q000592:standards; D011870:Radiologic Health; D011871:Radiology / Q000706:statistics & numerical data*; D012017:Referral and Consultation; D012307:Risk Factors; D012308:Risk Management / Q000379:methods; D012606:Scotland / Q000453:epidemiology