TY - JOUR
T1 - Unintended and accidental medical radiation exposures in radiology
T2 - Guidelines on investigation and prevention
AU - Martin, C. J.
AU - Vassileva, J.
AU - Vano, E.
AU - Mahesh, M.
AU - Ebdon-Jackson, S.
AU - Ng, K. H.
AU - Frush, D. P.
AU - Loose, R.
AU - Damilakis, J.
N1 - Funding Information:
A meeting was held at the IAEA Headquarters in Vienna, Austria, from 6 to 8 March 2017 which gave Member States, and international, regional, and national organizations an opportunity to exchange information on methods for identification and prevention of radiation incidents, and the investigation and reporting of unintended and accidental exposure in diagnostic radiology and interventional procedures when they occur. The Governments of all IAEA Member States and relevant international and professional societies were invited to nominate their representatives. The meeting was attended by 52 participants from 25 countries—radiologists, medical physicists, radiographers or radiologic technologists, regulators, and equipment manufacturers. The following organizations were represented: the Conference of Radiation Control Program Directors (CRCPD), the European Federation of Organisations for Medical Physics (EFOMP), the European Federation of Radiographer Societies (EFRS), the European Society of Radiology (ESR), the Global Diagnostic Imaging, Healthcare IT and Radiation Therapy Trade Association, the Heads of European Radiological protection Competent Authorities (HERCA), the International Commission on Radiological Protection (ICRP), the IAEA, the International Organization for Medical Physics (IOMP), the International Society of Radiographers and Radiological Technologists (ISRRT), the International Society of Radiology (ISR), the Image Gently Alliance and Image Wisely Campaign, the UK Society for Radiological Protection, the United Nations Scientific Committee on the Effects of Atomic Radiation (UNSCEAR), the WHO, and the WHO Patients for Patients Safety Network. Information and data were presented on incidents that had occurred and experiences shared in reporting of such events. Information included advice on reporting within healthcare facilities, methods for investigating to determine root causes, and discussion of factors that contribute to errors, as well as implementation of changes to avoid the recurrence of similar events in the future. Methods of good practice that can help to identify issues that might lead to exposures greater than intended were also discussed. In the latter part of the meeting, participants divided into working groups to discuss issues and prepare recommendations relating to different aspects of the topic. Information from the meeting has been collated in the form of guidance.
Funding Information:
1University of Glasgow, 27 Garngaber Avenue, Lenzie, G66 4LL, United Kingdom 2International Atomic Energy Agency, Vienna International Centre, 1400 Vienna, Austria 3Radiology Department, Complutense University, 28040 Madrid, Spain 4Johns Hopkins University, N. Caroline Street, Baltimore 21287-0856, United States of America 5Directorate, CRCE, Public Health England, Chilton, Didcot, Oxfordshire, OX11 0RQ, United Kingdom 6Department of Biomedical Imaging; University of Malaya, 50603 Kuala Lumpur, Malaysia 7Department of Radiology, Duke University School of Medicine, Durham, NC 27710, United States of America 8Hospital Nuremberg, Institute for Medical Physics, D-90340, Nuremberg, Germany 9Department of Medical Physics, Faculty of Medicine, University of Crete, Iraklion, Crete, Greece
Publisher Copyright:
© 2017 IOP Publishing Ltd.
PY - 2017/12
Y1 - 2017/12
N2 - This paper sets out guidelines for managing radiation exposure incidents involving patients in diagnostic and interventional radiology. The work is based on collation of experiences from representatives of international and national organizations for radiologists, medical physicists, radiographers, regulators, and equipment manufacturers, derived from an International Atomic Energy Agency Technical Meeting. More serious overexposures can result in skin doses high enough to produce tissue reactions, in interventional procedures and computed tomography, most notably from perfusion studies. A major factor involved has been deficiencies in training of staff in operation of equipment and optimization techniques. The use of checklists and time outs before procedures commence, and dose alerts when critical levels are reached during procedures, can provide safeguards to reduce the risks of these effects occurring. However, unintended and accidental overexposures resulting in relatively small additional doses can take place in any diagnostic or interventional x-ray procedure and it is important to learn from errors that occur, as these may lead to increased risks of stochastic effects. Such events may involve the wrong examinations, procedural errors, or equipment faults. Guidance is given on prevention, investigation, and dose calculation for radiology exposure incidents within healthcare facilities. Responsibilities should be clearly set out in formal policies, and procedures should be in place to ensure that root causes are identified and deficiencies addressed. When an overexposure of a patient or an unintended exposure of a foetus occurs, the foetal, organ, skin, and/or effective dose may be estimated from exposure data. When doses are very low, generic values for the examination may be sufficient, but a full assessment of doses to all exposed organs and tissues may sometimes be required. The use of general terminology to describe risks from stochastic effects is recommended rather than the calculation of numerical values, as these are misleading when applied to individuals.
AB - This paper sets out guidelines for managing radiation exposure incidents involving patients in diagnostic and interventional radiology. The work is based on collation of experiences from representatives of international and national organizations for radiologists, medical physicists, radiographers, regulators, and equipment manufacturers, derived from an International Atomic Energy Agency Technical Meeting. More serious overexposures can result in skin doses high enough to produce tissue reactions, in interventional procedures and computed tomography, most notably from perfusion studies. A major factor involved has been deficiencies in training of staff in operation of equipment and optimization techniques. The use of checklists and time outs before procedures commence, and dose alerts when critical levels are reached during procedures, can provide safeguards to reduce the risks of these effects occurring. However, unintended and accidental overexposures resulting in relatively small additional doses can take place in any diagnostic or interventional x-ray procedure and it is important to learn from errors that occur, as these may lead to increased risks of stochastic effects. Such events may involve the wrong examinations, procedural errors, or equipment faults. Guidance is given on prevention, investigation, and dose calculation for radiology exposure incidents within healthcare facilities. Responsibilities should be clearly set out in formal policies, and procedures should be in place to ensure that root causes are identified and deficiencies addressed. When an overexposure of a patient or an unintended exposure of a foetus occurs, the foetal, organ, skin, and/or effective dose may be estimated from exposure data. When doses are very low, generic values for the examination may be sufficient, but a full assessment of doses to all exposed organs and tissues may sometimes be required. The use of general terminology to describe risks from stochastic effects is recommended rather than the calculation of numerical values, as these are misleading when applied to individuals.
KW - computed tomography
KW - digital radiography
KW - effective dose
KW - foetal exposure
KW - interventional cardiology
KW - interventional radiology
KW - radiation incidents
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U2 - 10.1088/1361-6498/aa881e
DO - 10.1088/1361-6498/aa881e
M3 - Article
C2 - 28836506
AN - SCOPUS:85038619983
SN - 0952-4746
VL - 37
SP - 883
EP - 906
JO - Journal of Radiological Protection
JF - Journal of Radiological Protection
IS - 4
ER -