Organisations must learn from radiation incidents, says CQC
The CQC's annual report on how it enforces the Ionising Radiation (Medical Exposure) Regulations has been published. The report provides data on the number of notifications of errors where patients have received unintended exposure of radiation.
In 2019/20, over 44 million diagnostic imaging examinations were carried out on NHS patients in England, with over 30 million of these using ionising radiation. Activity across all types of imaging dropped slightly from the previous year, potentially due to the impact of the coronavirus (COVID-19) pandemic in March 2020.
The criteria for notifying CQC of incidents under the 2017 regulations changed in June 2019 to reduce the number of very low risk notifications that need to be reported. In the 2019/20 report, the CQC therefore looks at notifications received in the 10-month period between 3 June 2019 to 31 March 2020, and a 10-month equivalent period in 2018/19 for comparison.
The regulator received 407 notifications during this period, which is a major reduction of 52% from the same period last year (841). This is expected following the change in reporting thresholds and the impact of the COVID-19 pandemic on the level of activity in quarter 4 of 2019/20. This meant it received fewer notifications as many treatments and investigations were paused.
Of the notifications received, the majority were from diagnostic imaging (247 notifications), followed by radiotherapy (113 notifications), and nuclear medicine (47 notifications). A high number of errors are still happening because of inadequate checks. Although notifications relate to incidents where there is risk of harm, the majority do not result in harm to patients.
We had carried out 35 inspections before pausing our routine programme in March. Most enforcement action was taken in response to failures relating to procedures and protocols, where these were either missing, out of date or did not reflect clinical practice. In several cases there was insufficient support from medical physics experts for the service.
Professor Ted Baker, CQC’s Chief Inspector of Hospitals, said: “COVID has demonstrated the tremendous efforts of staff working across diagnostic radiology, nuclear medicine and radiotherapy who have adapted quickly to work in different ways to keep people safe. Their resilience and flexibility is clearly evidenced in this report and is to be commended.
“Although there was less activity across all types of imaging compared with the same period last year, and therefore fewer notifications of errors, workforce shortages remained – particularly among the medical physics workforce who play an important role advising on radiation protection and regulatory compliance, procuring equipment and supporting the training of staff. It is concerning that in several cases we found insufficient support from medical physics experts had led to delays in routine equipment testing and a lack of regular audits – prompting the need for enforcement action on our part.
“The number of incidents involving patients is small in the context of the many millions of radiation procedures undertaken each year, but in too many cases errors still happen as a result of inadequate checks, poor communication, or because of a failure to follow procedures around radiation protection.
“Organisations must learn from incidents and take action to mitigate the risks of repeating errors to protect patients. This report is a reminder to clinical leadership teams that a strong safety culture is vital and must be a priority.”