Adverse events due to unnecessary radiation exposure in medical imaging reported in Finland |
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Affiliation: | 1. Department of Diagnostic Radiology, Research Unit of Medical Imaging, Physics and Technology, Oulu University Hospital, POB 50, 90029 OYS, Oulu, Finland;2. Department of Diagnostic Radiology, Medical Research Center, Oulu University Hospital and University of Oulu, Finland;3. Department of Diagnostic Radiology, Oulu University Hospital, Finland;4. Department of Diagnostic Radiology, Research Unit of Medical Imaging, Physics and Technology, Oulu University Hospital and University of Oulu, Finland;5. Administrative Centre, Research Unit of Biomedicine, Oulu University Hospital and University of Oulu, Finland;1. Monash University, Southern Clinical School, Clayton, Victoria, Australia;2. Monash Imaging, Monash Health, Clayton, Victoria, Australia;3. Australian Patient Safety Foundation, Adelaide, South Australia, Australia;4. School of Psychology, Social Work and Social Policy, University of South Australia. Adelaide, South Australia, Australia;1. Center for Evidence-Based Imaging, Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts;2. Harvard Medical School, Boston, Massachusetts;3. Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts;4. Center for Work, Health, and Wellbeing, Harvard T.H. Chan School of Public Health, Boston, Massachusetts;5. Healthcare Systems Engineering Institute, Northeastern University, Boston, Massachusetts;1. Department of Medical Imaging and Radiation Sciences, Faculty of Health Sciences, University of Johannesburg, Johannesburg, South Africa;2. Department of Medical Imaging Sciences, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda;1. Department of Radiology, Odense University Hospital, Denmark;2. Research and Innovation Unit, University of Southern, Denmark;3. Faculty of Health Sciences, Oslo Metropolitan University, Norway;4. Faculty of Health Studies, University of Bradford, UK;5. Department of Radiography, University College Lillebaelt, Denmark;6. Lillebaelt Hospital, Department of Radiology, Denmark;7. School of Health Sciences, University of Ulster, UK |
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Abstract: | IntroductionAdverse events in radiology are quite rare, but they do occur. Radiation safety regulations and the law obligate organizations to report certain adverse events, harm and near misses, especially events related to patients' health and safety. The aim of this study was to describe and analyse incidents related to radiation safety issues reported in Finland.MethodsThe data were collected from incident reports documented by radiology personnel concerning notifications of abnormal events in medical imaging made to the Radiation and Nuclear Safety Authority between 2010 and 2017. During these eight years, 312 reports were submitted. Only events reported from radiology departments were included; nuclear medicine, radiotherapy and animal radiology cases were excluded. The final number of reports was 293 (94%).ResultsThe majority of the 293 approved reports were related to computed tomography (CT, 68.3%) and to X-ray examinations (27.6%). Altogether 82.9% of those irradiated were adults, most of whom were exposed to unnecessary radiation through CT (86.5%), 5.5% were children, and 4.4% pregnant women. The most common effective dose of unnecessary radiation was 1 mSv or less (89.7% of all examinations). The highest effective doses were reported in CT (from under 1 mSv–20 mSv and above). The reasons for the adverse events were incorrect identification (32%), incorrect procedure, site or side (30%); and human errors or errors of knowledge (20%).ConclusionAdverse events occurred especially in CT examinations. It is important to collect and analyse incident data, assess the harmful events, learn from them and aim to reduce adverse events.Implications for practiceThis study emphasizes the need for radiological personnel to obtain evidence-based information on adverse events and focus on training to improve patient safety. |
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Keywords: | Adverse events Incident reporting Imaging errors Patient safety STUK" },{" #name" :" keyword" ," $" :{" id" :" kwrd0035" }," $$" :[{" #name" :" text" ," _" :" Radiation and Nuclear Safety Authority of Finland ST" },{" #name" :" keyword" ," $" :{" id" :" kwrd0045" }," $$" :[{" #name" :" text" ," _" :" Guides Radiation Safety Guides IOM" },{" #name" :" keyword" ," $" :{" id" :" kwrd0055" }," $$" :[{" #name" :" text" ," _" :" Institute of Medicine CTDI" },{" #name" :" keyword" ," $" :{" id" :" kwrd0065" }," $$" :[{" #name" :" text" ," _" :" Computer Tomography Dose Index IAEA" },{" #name" :" keyword" ," $" :{" id" :" kwrd0075" }," $$" :[{" #name" :" text" ," _" :" International Atomic Energy Agency |
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