Care Quality Commission
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First report on x-ray and radiological incidents shows that one in three involve the wrong patient and that reporting is patchy.

The Healthcare Commission today calls on NHS and independent sector hospitals to ensure they are not exposing patients to the dangers of unnecessary radiation through x-rays, CT scans and other procedures.

In the first report of its type, the Commission analyses 329 incidents reported to it during the 14 month period from November 2006 to December 2007 under the Ionising Radiation (Medical Exposure) Regulations (2000).

Exposure to ionising radiation is a vital part of healthcare provision and can save lives, but it does have the potential to cause harm and in extreme cases can increase the risk of cancer. The Commission stresses that the majority of incidents reported to it were of a low dose and carry little risk to patients.

The report states that a third of the errors occurred when x-rays and other diagnostic examinations were carried out on the wrong patient. In radiotherapy, where doses are higher, patient identification was not an issue.

The report also highlights variations in the number of incidents reported by NHS trusts and other healthcare providers, with many organisations reporting no errors but some reporting up to 18 in this period. The Commission encourages the reporting of incidents saying this is an indication of a positive safety culture.

Under the regulations, healthcare providers must report to the Commission incidents where patients experience a dose of radiation “much greater than intended”.

The Commission states that NHS trusts and independent hospitals must ensure the use of x-rays and other radiations is justified, doses are kept as low as possible and incidents are reported where appropriate.

The Commission is currently inspecting around half of the radiotherapy centres in England. It will also be inspecting other healthcare providers where it believes there may be a risk to patients.

While stressing that the majority of cases reported to the Commission involved a low dose of radiation, a third of x-ray incidents (80 in total) involved CT scanning, where radiation doses are at the upper end of the diagnostic spectrum.

Most x-rays and other diagnostic and therapeutic radiation exposures are performed without incident. The number of incidents represent a very small fraction of the total number of procedures carried out – less than 1 in every 88,000 procedures.

The incidents were reported by 107 organisations – 96 NHS acute trusts, nine independent sector providers and two primary care trusts.

Seventy-seven NHS acute hospital trusts have reported no incidents to the Commission, which may indicate high levels of safety or a poor reporting culture. Some of these trusts will be included in follow up inspections to ensure that they have systems in place for robust reporting. In considering where to inspect, the Commission will use data from a range of sources, including surveys of staff asking about the number of incidents they have reported.

The number of errors reported to the Healthcare Commission under the regulations is almost double the number reported to the Department of Health under previous arrangements. The increase may be the result of greater awareness of the notification processes or easier access to the notification system via an online tool.

In a third of all incidents reported, the errors were caused because x-rays or other tests were given to the wrong person. Patient identification failures occur for a variety of reasons but a common mistake is when the doctor puts the wrong patient identification sticker on the x-ray request form or selects the wrong patient from a computer system. Sometimes the wrong patient may be collected from the ward and inadequate checks carried out on their identity.

Specifically, the incidents reported comprise:

  • Diagnostic x-rays including CT scans (240 incidents) - the most common error was x-raying the wrong patient (44%), followed by operator error such as failing to follow correct procedures (35%), imaging the wrong part of the body (10%) and procedures being unnecessarily repeated (10%).
  • Radiotherapy treatment (66 incidents) for cancer patients - the most common incidents related to a treatment error (64%), including missing the designated site. Other errors were the result of planning mistakes such as writing the wrong instructions for people delivering treatment (20%), referral mistakes such as prescribing the wrong dose (11%), and other issues (5%).
  • Nuclear medicine (23 incidents), where radioactive substances were injected into a patient for imaging purposes - over half (52%) the errors related to a treatment error, such as carrying out the wrong test or administering the wrong radioactive substance. Other incidents related to carrying out procedures on the wrong patient (35%) and foetal exposure where the woman had not declared she was pregnant (13%).

Anna Walker, Chief Executive of the Healthcare Commission, said: “The NHS carries out some 25 million x-rays and other procedures using radiation each year – the vast majority of which are carried out safely.

“We applaud those trusts that have reported incidents to us – this shows that they have systems in place for identifying when things go wrong and this is the first step in learning from mistakes.

“Our report shows that over 300 people in this period have been given an unnecessary dose of radiation, which can cause distress, and in extreme cases, has the potential to cause harm. In a third of the cases reported to us, the wrong patient has been x-rayed. Employers and staff must do all they can to prevent exposing patients to unnecessary radiation.

“Following an assessment of risk based on a range of data, we will be contacting organisations to ensure they have proper systems in place for reporting when things go wrong and learning from mistakes.”

Some healthcare providers that have not referred any incidents to the Healthcare Commission will be included in the inspection programme. This is to identify whether they have not experienced any errors or if they have failed to report those errors they have experienced.

The Healthcare Commission took over responsibility for regulating the medical use of ionizing radiation from the Department of Health in 2006 at the request of the Department of Health.

The Commission is working with the National Patient Safety Agency, the Department of Health and the Royal College of Radiologists to ensure that lessons are learnt from incidents and appropriate guidance is available.

Ionising Radiation (Medical Exposure) Regulations 2000 - A report on regulation activity from 1 November 2006 to 31 December 2007

More information on Ionising Radiation (Medical Exposure) Regulations 2000

Notes to editor

The Ionising Radiation (Medical Exposure) Regulations 2000 are in place to safeguard patients undergoing medical examination or treatment using ionising radiation.

The regulations require radiological examinations of patients to be individually justified by a practitioner who is aware of the risks and benefits of the exposure.

The problems and risks of inadequate patient identification were first identified in the document published by the NHS Executive in its guidance document HSG 95(3) in January 1995.

Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services.

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information, contact Creina Lilburne in the Healthcare Commission press office on 020 7448 9439 or after hours on 07941 156 827.

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