The State’s health watchdog received notifications of 76 accidental and unintended exposures to ionising radiation at Irish hospitals and imaging facilities last year, an increase of 11 per cent on 2019.
The Health Information and Quality Authority (Hiqa) said the most common error reported involved medical exposures to the wrong patient, which accounted for 34 per cent of all notifications.
Hiqa has published its annual overview report of lessons learned from receiving statutory notifications of accidental and unintended exposures to ionising radiation in 2020.
Medical exposure to ionising radiation is when radiation is used as part of diagnosis such as a dental X-ray or CT scan or the use of radiotherapy as part of cancer treatment at a hospital.
It also includes radiation received for medical research purposes and radiation received by carers and comforters while attending a patient.
Hiqa said the 76 notifications were “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 majority (65) of notifications received were from diagnostic imaging services with the remaining 11 submitted from radiotherapy services.
Notifications from the procedures of interventional cardiology, mammography, and fluoroscopy were also received for the first time.
Human error was identified as the main cause in 58 per cent of notifications received.
However, it was found other factors contributed to these errors in the vast majority of incidents.
Of the 160 public and private hospitals and imaging facilities, 31 facilities reported 65 notifications in 2020.
This meant that less than 20 per cent of all medical facilities notified Hiqa of a significant event last year.
One-third of these notifications were reported by five facilities, and 16 out of the 31 facilities reported at least two significant events within this time period.
Many services with high levels of activity and providing complex medical exposures did not report any significant event, Hiqa said.
“The lack of reporting in these services may be indicative of consistently good practice. Alternatively, it may suggest that not all errors or incidents that occur are identified or reported,” the watchdog added.
John Tuffy, Hiqa's regional manager for ionising radiation, said inspections of medical exposure to ionising radiation in 2020 found that the management of accidental and unintended exposures was "generally good".
“However, there is room for improvement in local incident management systems,” he said.
“We welcome the increase in reporting in 2020, as it potentially suggests a more open and positive patient safety culture. The increase in reporting is a positive indicator, particularly in the context of the unprecedented additional challenges faced by undertakings during the Covid-19 pandemic.”
