HIQA publishes first overview report on significant events of accidental or unintended medical exposures reported in 2019
The Health Information and Quality Authority (HIQA) has today published an overview report on the lessons learned from notifications of significant incident events arising from accidental or unintended medical exposures in 2019. This report provides an overview of the findings from these notifications and aims to share learnings from the investigations of these incidents.
In 2019, HIQA received 68 notifications of significant events of accidental or unintended medical exposures to patients in public and private facilities, which is a small percentage of significant incidents relative to the total number of procedures taking place which can be conservatively estimated at over three million exposures a year.
The most common errors reported were patient identification failures, resulting in an incorrect patient receiving an exposure. These errors happened at various points in the patient pathway which, while in line with previous reporting nationally and international data, highlights an area for improvement for undertakings. Further potential learnings are included within the report.
John Tuffy, Regional Manager for Ionising Radiation, said “The overall findings of our report indicate that the use of radiation in medicine in Ireland is generally quite safe for patients. The incidents which were reported to HIQA during 2019 involved relatively low radiation doses which posed limited risk to service users. However, there have been radiation incidents reported internationally which resulted in severe detrimental effects to patients so ongoing vigilance and attention is required. “
When reviewing the corrective measures applied by undertakings following the occurrence of a significant event, a varied approach to patient safety was found. While a frequent corrective measure was the re-education of staff; undertakings should consider other risk management strategies, such as simplifying or standardising procedures or the automation of processes to help prevent errors from reoccurring.
John Tuffy, continued “As the regulator of medical exposures, HIQA has a key role in the receipt and evaluation of notifications received. While a significant event is unwanted, reporting is a key demonstrator of a positive patient safety culture. A lack of reporting does not necessarily demonstrate an absence of risk. Reporting is important, not only to ensure an undertaking is compliant but because it improves general patient safety in a service and can minimise the probability of future preventative events occurring.”
It was noted that in many of the notifications submitted, there was an emphasis on the error of an individual or individuals involved in the process, rather than the evaluation of the system error that lead to such incidents.
John Tuffy has said “It is hoped that the key areas identified in this report will inform service providers of the types of issues that are common in diagnostic radiology and radiotherapy facilities but will also assist learning to prevent future preventable incidents occurring.”
You can read the report here.
HIQA’s 2019 Overview report on accidental or unintended medical exposures to ionising radiation