HIQA has encouraged facilities to review their reporting pathways to ensure a strong
culture of radiation safety awareness and associated learning.
HIQA made the call as it published its annual overview report of lessons learned
from receipt of statutory notifications of accidental and unintended exposures to
ionising radiation in 2021. This report provided an overview of the findings from
these notifications and shared learnings from the investigations of these incidents.
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. HIQA said low rates of reporting might suggest a lack of
reporting rather than a lack of incidents.
The organisation said 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 remained 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 encouraged facilities to make system-focused changes as, it
said, they had 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, HIQA said facilities should ensure that systems and processes
were 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
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.”