Increase in number of patients accidentally exposed to ionising radiation in Irish hospitals last year

File picture of a patient being set up to have a Computed Tomography (CT) scan. Picture: PA

76 people were unintentionally exposed to ionising radiation in Irish hospitals in 2020, according to the Health and Information Quality Authority (HIQA). 

This figure represents an 11% increase on the total reported in 2019.

HIQA today published an overview report on the 'increase in accidental and unintended exposure to ionising radiation events notified to HIQA in 2020. It is HIQA's second such annual report.

In 2019, new regulations were put in place to transpose into Irish law the EU Council Basic Safety Standards (BSS) Directive of 2013.

Under the European Union (Basic Safety Standards for Protection against dangers arising from Medical Exposure to Ionising Radiation) Regulations 2018 and 2019, HIQA is the competent authority for patient protection in relation to medical exposure to ionising radiation in Ireland.

In its 2019 report — its first such publication — HIQA expressed hope that the areas of improvement it identified "would help reduce the likelihood of such events and drive quality improvements in safety mechanisms for medical exposures in Ireland."

Despite this, eight more accidental exposure incidents were recorded in 2020 than in the previous year.

Today we published our second annual overview of the lessons learned from radiation incidents reported to HIQA. See more here: https://t.co/m6UZ5QDR3o pic.twitter.com/yWliIDy61u

— HIQA (@HIQA) September 15, 2021

According to HIQA, medical exposure to ionising radiation is classified as an incident where radiation is used as part of diagnoses such as a dental X-ray or Computed Tomography scan, or the use of radiotherapy as part of cancer treatment at a hospital.

These incidents can also relate to radiation received for medical research purposes and radiation received by carers and comforters. 

Overall, 65 of the accidental exposure incidents last year occurred in diagnostic imaging, mainly Computed CT services.

The remaining 11 incidents occurred in radiotherapy services.

Some of the exposures related to fluoroscopy, mammography, and interventional cardiology  — the first time incidents were reported in these areas.

Human error

Human error was identified as the main cause of accidental exposure in 58% of the incidents, however, HIQA determined that other factors likely contributed to these.

Some 34% of the incidents involved the wrong patient being exposed to ionising radiation. HIQA said these exposures occurred at varying points along the medical exposure pathway.

It stressed that the number of unintended exposure to ionising radiation incidents last year was small compared with the total number of procedures carried out, estimated to be in the region of three million.

John Tuffy, Regional Manager for Ionising Radiation said the report showed there was "room for improvement in local incident management systems.” 

“We welcome the increase in reporting in 2020, as it potentially suggests a more open and positive patient safety culture. 

Mr Tuffy said the increase in reporting was "a positive indicator", particularly in the context of "the unprecedented additional challenges faced by undertakings during the Covid-19 pandemic.

Sean Egan, Head of Healthcare Regulation at HIQA said the authority would "continue to build upon its programme to date to promote patient safety in relation to radiation protection and to improve the quality and safety of services for all." 

"We hope that the areas for learning identified in this report, particularly around safety measures to enhance patient identification, will aid service providers in protecting patients against future preventable incidents of accidental or unintended exposure.”

The full overview report of lessons learned from receipt of statutory notifications of accidental and unintended exposures 2020 can be read on the HIQA's website https://www.hiqa.ie/reports-and-publications/key-reports-investigations/overview-report-lessons-learned-receipt