Radiation Incident Reporting

Reporting Incidents (effective from 12th April 2010).

Medical Incident Definitions (Hospitals, DXA and Chiropracty) and Notification Process

Dental Incident Definition and Notification Process

Patient Radiation Incidents that meet the requirements outlined in the Notification Process (above) are required to be reported to the Medical Exposure Radiation Unit and are brought to the attention of the National Radiation Safety Committee at its quarterly meetings.

The purpose of this reporting mechanism is to provide the committee with information on types and causes of patient radiation incidents, enabling the identification of recurring incidents and trends.  The Committee or the MERU may provide advice to the CEO and locations to assist in preventing recurrence.  Locations can compare local practices with national averages and lessons learned from similar incidents occurring elsewhere. 

When to report a patient radiological incident.

You can report an incident by contacting the Medical Exposure Radiation Unit at 01620 1624 or email rose.lindsay@hse.ie. If you are unsure as to whether the incident needs to be reported, you can contact the Unit to discuss.

What to do when an incident occurs.

The incident should be managed as normal within the risk management process of the organisation.  The requirement to report an incident to the Medical Exposure Radiation Unit is separate to the normal management of an incident at the location. 

What happens next?

Once we are notified of an incident, we will expect the incident to be investigated through to closure and a copy of the investigation sent to the unit.

When processing notifications, we will expect to see evidence of internal governance, such as operating within the quality and safety protocols of the organisation, an internal investigation showing what went wrong, what was learned and the details of any action taken to reduce the likelihood of similar incidents in the future.  A sample investigation template with prompt questions is available which can be referred to, adapted or integrated in to the location's investigation template.  A systems analysis approach is recommended, an example of this is documented in the HSE document Toolkit of Documentation to Support the Health Service Executive Incident Management (2009)Patient Communication protocols/ open disclosure protocols should also be noted in investigations, some sample documents are available here.

There may be situations where the exposure was the result of equipment malfunction, or a wrong patient received radiation. In these circumstances you may also have to inform the Radiological Protection Institute of Ireland (RPII).  Click here for more information.  Please ask your Radiation Protection Advisor for advice.

In addition, you should follow the adverse incident reporting process for medical devices managed by the Irish Medicines Board.

Incident Reporting Investigation Templates (incident reporting to MERU)

The MERU has designed incident reporting templates which should be used by locations for their investigations on patient radation incidents for reporting to the MERU. Template can be obtained here. The templates address all the objectives required to carry out a thorough investigation of incidents. The five main objectives in investigating incidents are;

  1. Ascertain events leading to the incident.
  2. Establish the cause of the incident.
  3. Implement immediate action to prvent further harm or reoccurence.
  4. Estimate dose received by patient.
  5. Record exposure factors and other relevant technical details.

It would be expected that the report will address at minimum the following;

  1. All relevant facts concerning the incident.
  2. Consequences for exposed patient.
  3. calculations and measurement of all exposures and other technical factors.
  4. Details of discussions if any, with patients and carers.
  5. Recommendations to avoid reoccurence.
  6. Details of follow up actions with staff involved.
  7. Details of follow up actions with the patient involved.

Incident Reporting Investigation Template

 

Recording of Incidents at Location

Many incidents of a more routine nature do not need to be reported to the Medical Exposure Radiation Unit and an investigation report submitted. However, the NRSC is also interested in identifying the number of all patient radiation incidents recorded at locations. Locations will be asked for returns on an annual basis by completing an Patient Radiation Incident Record form.

Locations are encouraged to ensure that they have an effective mechanism that identifies and facilitates the recording of patient radiation incidents, which may require updating risk management protocols and incident recording forms. A national patient radiation incident form has been adopted for radiotherapy centres (2013) which will provide consistency in incident recording.

Patient Radiation Incident Recording Form for recording Radiotherpay Incidents locally.

Patient Radiation Incident Recording Form for recording Diagnostic Radiology Incidents locally.

 

MERU Incident Reports

Incidents Report MERU 2013 - 2015.pdf (size 512.3 KB)

Incidents Reported to MERU, HSE 2010 to 2012.

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