CT scan errors led to patients being exposed to ‘low-level’ radiation

Errors were made in the provision of CT scans to almost 50 patients last year, resulting in an accidental exposure to low levels of radiation.

There were 68 notifications of significant exposure to ionising radiation to patients in 2019, a small number relative to the estimated three million radiological procedures carried out each year, according to the Health Information and Quality Authority (Hiqa).

The most common error reported in diagnostic imaging involved failures in patient identification, resulting in the wrong patient receiving an exposure. Hiqa says failures in identifying the correct patient occurred at various points in the patient pathway, from the point of referral to initiating the exposure.

“While this finding is in line with previously reported national and international data, it certainly highlights an area for improvement for undertakings,” the report states.

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CT scans accounted for 68 per cent of the 68 notifications received, with radiotherapy accounting for 19 per cent and nuclear medicine for 10 per cent.

Identify

Of the CT scans, almost half related to either the wrong patient being referred or errors in failing to correctly identify patients at the point of exposure.

"The report indicates the use of radiation in medicine in Ireland is generally quite safe for patients," says John Tuffy, ionising radiation manager with Hiqa. "The incidents which were reported 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.

“While the occurrence of any significant incident is unwanted, incident reporting can be suggestive of a positive and transparent patient safety culture within a service,” the report notes.

“Low levels of reporting could be suggestive of a lack of reporting rather than a lack of errors.”

Hiqa says some investigation reports it received focused on human error in isolation, without considering this as a symptom of wider weaknesses in the system.