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The 29 notifiable incidents from radiology included two cases of “inadvertent dose to foetus” through CT scans. Additionally, there were three cases of “exposure greater than intended” through CT scans, three through general x-ray and one through nuclear medicine.
Radiotherapy reported three cases of “inadvertent dose to foetus”, one case of “incorrect anatomy” and one case of dose or volume variation from the fraction prescribed.
The NRSC annual report noted: “The most common cause of error reported involved the operator, referrer or administrator identifying the wrong patient for a diagnostic procedure. This finding is important and the NRSC recommends that all locations initiate an awareness campaign in 2017 to highlight to practitioners the importance of complying with a triple-identification policy.”
There were no notifiable incidents reported to the Medical Exposure Radiation Unit (MERU) that involved interventional radiology or non-radiology/radiotherapy medical specialties which routinely administer ionising radiation to patients, the report critically noted.
The 34 notifiable incidents reported in 2016 compared with 53 the previous year. Sixty locations had completed and returned the annual returns template to MERU for 2016, although almost 100 public and private radiology and radiotherapy locations in Ireland are licensed to administer medical ionising radiation to patients.
A HSE spokesperson told the Medical Independent that MERU issued correspondence to all Hospital Group CEOs, hospital CEOs and all radiology and radiotherapy departments highlighting the importance of reporting incidents in line with the MERU Patient Radiation Protection Manual. MERU is engaging with HIQA, as the future competent authority for patient radiation safety, to support the forthcoming transition and ensure continuity post-February 2018. MERU has advised HIQA to include all areas where patients receive medical ionising radiation into their new regulatory framework.
In relation to incidents where a dose of radiation was given to pregnant patients, the spokesperson said the patients concerned did not know that they were pregnant at the time of treatment. MERU has not been advised of any adverse outcomes or legal proceedings in this regard.