Study aims, objectives and significance
Aims:
Objectives:
Significance:
Expands analysis to multiple nations in the British Isles simultaneously
Who are the REAs?
Relevant Enforcing Authorities:
Background
The Care Quality Commission in England publish annual IRMER reports (CQC, 2022) with limited analysis of only reportable incidents of significant accidental and unintended exposure (SAUE).
As most incidents are nonreportable, this study aims to investigate the gap in data provided by the Relevant Enforcing Authority (REA) by analysing these.
This study considers reports of all radiation incidents, including SAUEs and incidents non-reported to the REAs.
The study also expands the analysis to include healthcare providers across multiple UK nations and a crown-dependency.
Method
A database was created manually, with data inputs from case files of 2888 reports of radiation incidents, provided by 121 healthcare providers to (IRS Ltd.) their appointed MPE, during the years 2020 – 2024.
Each radiation incident report was tagged using a UK categorisation method, the RCR coding taxonomy (RCR, 2019).
The data for each code category was analysed quantitatively to produce a count and percentage of total reports.
Results
General trend analysis shows most incidents are non-reportable to REAs, only 4% were reportable SAUEs.
Exposure Types were mostly Medical Exposure (96%).
Figure 1. shows the performed modalities stacked by “intended” modality.
Imaging modes for radiation incidents were usually performed as intended, the most common were Radiology, Computed Tomography, Mammography and Fluoroscopy.
Figure 2. shows the proportion of incidents at the Duty Holder level, not showing the Practitioner sub-level.
Most incident Duty Holders were the Operator (67.7%), the Referrer (13.5%), and None (12.2%).
Table 1. lists the most frequent contributory factors (CF) alongside the relevant Duty Holder for radiation incidents.
A variety of CFs for radiation incidents occur frequently when the Operator is Duty Holder. When the Duty Holder is ‘None’, ‘Equipment related’ factors occur at 11.2%.
Conclusion
2888 radiation incidents were analysed, including analysis of 2772 ‘nonsignificant’ incidents, not reported to the REA.
In contrast with the CQCs analysis of reportable incidents, the most common modalities for radiation incidents were General Radiology, CT and Mammography. This is to be expected as the established reporting criteria focuses mainly on effective dose received, and these generally low dose procedures only tend to be reportable under the complimentary notification criteria for incidents with similar themes or involving multiple individuals.
Common themes were identified, including majority of incidents from the Operator which agrees with CQC findings. The most frequent causes were identified providing a better trend analysis for healthcare providers. This database can assist employers with their legal duty, under IRMER regulation 8, to establish a system of trend analysis (gov.uk, 2017).
Future Development
Potential areas of further research include a more extensive analysis the data, and a comparative study between CQC and our findings.
There is potential for more trend analysis to compare radiation incidents by the following factors: regional or national, public and private sector, type of healthcare provider (hospital, community, dental), differences over time, equipment type, and linkage of CFs.
Another area of research is to establish a Modality rate per 100,000 patients, to allow for more useful comparison.
An automated analysis process is being developed to analyse radiation incidents by different criteria, such as modality, responsible duty Holder and root cause, to assist employers to monitor themes and trends for individual sites and trusts.
Presented by:
James Melia-Jones, Rhiannon Winwood, Ryan Jones, Michael Richardson, Jalendra Singh Dussaye, Jonny Mitchell, Jason Fazakerley
References
Available at: https://www.legislation.gov.uk/uksi/2017/1322/made [Accessed 9 February 2024].