Reporting overexposures and unintended exposures in diagnostic procedures.
Legislation requires the reporting to regulatory authorities of incidents in which patients have been exposed to ionizing radiation to an extent "much greater than that intended". The authorities have published guidance on what is considered to meet this requirement. However, there is still some confusion regarding, particularly, the necessity to report some unintended doses. It is believed that there is a disproportionate amount of resource spent investigating some unintended exposures because all such exposures will have an effective overexposure factor of infinity, irrespective of the magnitude of the dose and the associated risk. This paper proposes changing the definitions of "overexposure" and "unintended exposure" and the adoption of a reporting process based upon risk assessment. All records and data would be collected and, if required, reported, but investigation of individual incidents would take place only for incidents carrying a greater risk than 1 in 10,000.
Clewer
P R
PR
Department of Medical Physics and Bioengineering, Southampton General Hospital, Southampton, UK. philip.clewer@suht.swest.nhs.uk
Jackson
P C
PC
D006801:Humans; D019300:Medical Errors / Q000331:legislation & jurisprudence*; D017410:Practice Guidelines as Topic; D011829:Radiation Dosage; D011834:Radiation Monitoring / Q000331:legislation & jurisprudence*; D012308:Risk Management