Maladministrations in nuclear medicine: revelations from the Australian Radiation Incident Register.
OBJECTIVE
To describe the incidence, type, causes and consequences of nuclear medicine maladministrations.


METHODS
Review of prospectively acquired maladministration reports within the Australian Radiation Incident Register (ARIR), a mandatory incident register managed by the Australian Radiation Protection and Nuclear Safety Agency.


METHODS
Individual reports from 2007 to 2011 were evaluated for dose of radiation exposure and type, cause and consequence of maladministrations. Incidence was estimated using data from Medicare Australia.


RESULTS
There were 149 maladministrations and the estimated incidence was 5.8 per 100,000 nuclear medicine procedures (95% CI, 5.0-6.9). About half of all maladministrations (48%) arose from an incorrect radiopharmaceutical being prepared and/or dispensed. Other causes included mistakenly injecting the wrong radiopharmaceutical because of inattention (n = 27; 18.1%); extravasations, failures in equipment or procedure leading to a non-diagnostic study (n = 25; 16.8%); misinterpreting a request form and performing an incorrect procedure (n = 13; 8.7%); or injecting an incorrect patient (n = 13; 8.7%). ARIR reports focused on active rather than latent causes. Most (n = 147) maladministrations occurred following diagnostic procedures, and the mean effective radiation dose was 7.9 mSv (range, 0.015-45 mSv). Two therapeutic maladministrations likely caused unintended organ injury.


CONCLUSIONS
The ARIR provides unique insight into the type, causes and complications of maladministrations in Australia. Nearly all maladministrations occur in a diagnostic context, and the risk of patient harm appears low. Among active causes, radiopharmaceutical preparation and dispensation, and medical supervision before injection merit attention. The ARIR could be refined by attending to latent errors, addressing possible underreporting and securing more complete Medicare data.
Nuclear Medicine and Ultrasound, Westmead Hospital, Sydney, NSW, Australia. george.larcos@health.nsw.gov.au.
George S
GS
Larcos
Nuclear Medicine and Ultrasound, Westmead Hospital, Sydney, NSW, Australia.
Lee T
LT
Collins
Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia.
Andrew
A
Georgiou
Centre for Health Systems and Safety Research, Australian Institute of Health Innovation, University of New South Wales, Sydney, NSW, Australia.
Johanna I
JI
Westbrook
D001315:Australia / Q000453:epidemiology; D006801:Humans; D037141:Mandatory Programs / Q000706:statistics & numerical data; D019300:Medical Errors / Q000706:statistics & numerical data*; D009683:Nuclear Medicine / Q000592:standards / Q000706:statistics & numerical data*; D011829:Radiation Dosage; D011832:Radiation Injuries / Q000453:epidemiology* / Q000209:etiology; D012042:Registries / Q000706:statistics & numerical data*