Manaaki Tangata Taiao Hoki protecting people and their environment through science Specialist Science Solutions HEAPHY 1 & 2 PLENARY Tony COTTERILL Fri 30 th Aug 2013 Session 3 / Talk 4 14:30 – 14:50 ABSTRACT This presentation will be in two parts: Under the Radiation Protection Act 1965 practitioners require a license to use irradiating apparatus and/or radioactive materials for medical imaging. Through a license condition licensees are required to report to the regulatory authority specified radiation incidents involving the exposure of patients. In diagnostic radiology notified radiation incidents are generally of low dose and consequently minimal risk. However, a significant proportion of notified incidents involve computerized tomography scans where patient doses are more significant. Also, on rare occasions incidents have included procedures involving the injection of patients with contrast media or radiopharmaceuticals. Causes of incidents include clerical errors, failure of staff to follow the so-called three-point check (e.g. name, date of birth and address), and referral errors such as the mislabeling of a request form. This presentation will give a summary of reported incidents in diagnostic radiology between July 2009 and the end of November 2011. The National Radiation Laboratory (NRL) has surveyed the use of conventional plain radiography in New Zealand since 1983. Since NRL's last supplemental survey in 1992 there have been improvements in technology, particularly with the widespread transition from film to digital imaging indicating the need for a new survey. The most recent survey was carried out by NRL in 2010 and involved collecting data nationally. This presentation reports the findings for this latest survey and presents national diagnostic reference levels
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Manaaki Tangata Taiao Hokiprotecting people and their environment through science
Specialist Science Solutions
HEAPHY 1 & 2
PLENARY
Tony COTTERILL
Fri 30th Aug 2013
Session 3 / Talk 4
14:30 – 14:50
ABSTRACT
This presentation will be in two parts:
Under the Radiation Protection Act 1965 practitioners require a license to use irradiating apparatus and/or radioactive materials for medical imaging. Through a license condition licensees are required to report to the regulatory authority specified radiation incidents involving the exposure of patients.
In diagnostic radiology notified radiation incidents are generally of low dose and consequently minimal risk. However, a significant proportion of notified incidents involve computerized tomography scans where patient doses are more significant. Also, on rare occasions incidents have included procedures involving the injection of patients with contrast media or radiopharmaceuticals. Causes of incidents include clerical errors, failure of staff to follow the so-called three-point check (e.g. name, date of birth and address), and referral errors such as the mislabeling of a request form.
This presentation will give a summary of reported incidents in diagnostic radiology between July 2009 and the end of November 2011.
The National Radiation Laboratory (NRL) has surveyed the use of conventional plain radiography in New Zealand since 1983. Since NRL's last supplemental survey in 1992 there have been improvements in technology, particularly with the widespread transition from film to digital imaging indicating the need for a new survey. The most recent survey was carried out by NRL in 2010 and involved collecting data nationally. This presentation reports the findings for this latest survey and presents national diagnostic reference levels
Manaaki Tangata Taiao Hokiprotecting people and their environment through science
Specialist Science Solutions
Diagnostic Radiology: 1/ A Summary Of Reported Radiation Incidents2/ The Results of a National Survey Of Patient Doses In Conventional Plain Film Radiography
Tony Cotterill, Glenn StirlingNational Centre for Radiation Science
Analysis of causes (1)Cause Additional details provided on causes Corrective and preventive
actions taken by radiology departments
Equipment failure.
These include: Patients administered radiopharmaceuticals just
prior to imaging equipment failure. Servicing error on fluoroscopy unit. CR cassette failure. Image storage computer failure. Image processor failure.
Limited possible actions as faults were unpredictable.
Inadequate procedures.
Hand-over issues when main ordering system that had been down was restored.
Hand-over issues between ED and Radiology. Incorrect patient identification. Accidental CR cassette erasure. Inadequate training of staff on x-ray equipment.
Process review and staff training.
Human error. Most involved misidentification of the patient.
Process review and staff training. More consistent application of the
Analysis of causes (2)Clerical error. Referral incorrectly entered on to RIS.
CT images accidentally deleted. NM images accidentally corrupted while
attempting amendment. Incorrectly booked for an x-ray when only a US
had been requested. Misinterpreted ambiguous exam coding. Patient previously administered with
radiopharmaceutical, mistakenly turned away when returned for scan.
Process review and staff training. Computerised referral systems. Computerised post-processing of
images.
Referrer error. Most involved referral forms with inaccurately completed clinical details (eg, forms where the incorrect pre-printed patient’s details label had been inadvertently attached), or duplicate requests.
Checking of clinical details with patients when presenting.
Computerised referral systems.
Other. Mostly due to patients not knowing that they were pregnant.
Staff training. Consideration of the use of
pregnancy tests for the high dose abdominal CT procedures.
Relative frequency of the main types ofconventional radiography procedures
• The contribution of conventional plain radiography procedures to the diagnostic radiology population dose per capita has dropped (243 to 99 µSv per capita per annum)
This is probably because of a shift of higher dose procedures to other modalities such as CT
• There has been a small increase in the number of conventional plain radiography procedures being performed compared to 1983/84
• The age distribution of patients undergoing conventional plain radiography procedures, since NRL’s survey in 1983-84, shows a marked increase in the x-raying of older adults withless paediatric x-rays. Demographics alone do not account for this shift
• The contribution of conventional plain radiography procedures to the diagnostic radiology population dose per capita has dropped. This is because of a shift of procedures to modalities such as CT.