Adamson Helen Katie, Foster Beverley, Clarke Ruth, Scally Andrew, Snaith Beverly
Mid Yorkshire Hospitals NHS Trust, Wakefield, United Kingdom.
University college Cork, Cork, Ireland.
J Patient Saf. 2022 Oct 1;18(7):e1096-e1101. doi: 10.1097/PTS.0000000000001022. Epub 2022 May 7.
This single-center review explores trends in computed tomography "radiation incidents" and suggests strategies for improvement.
A retrospective mixed-methods approach was used in this longitudinal evaluation of radiation incidents within a multisite NHS Trust in northern England. DATIX was interrogated at the Trust level to identify all records linked to radiation incident in computed tomography departments between January 1, 2015, and December 31, 2018.
During the 4-year review period, 159,596 exams were performed at the Trust and a total of 133 incidents were recorded. This comprised 42.1% (n = 56) of radiation incidents, 43.6% (n = 58) of near-miss incidents, and 14.3% (n = 19) of repeat scans due to extravasation of contrast. The reported radiation incident rate was 0.08%. These data suggest an approximation of 1 incident per thousand cases. Most incidents were investigated using a "system approach," and the reports highlighted the relevant action that had been taken to try and prevent recurrence of the incident. Qualitative data collected from the root cause analysis minutes demonstrated themes related to the contributory factors, incident analysis performed, and overall learning.
Computed tomography departments need to focus on a system approach instead of the "person approach" to identify areas where efficiencies can be implemented. Staff should feel open to discuss system inefficiencies that they experience and may highlight problems the management is unaware of. The reporting of all types of incidents, including near misses, should be encouraged, to foster an open culture and to expand learning.
本单中心综述探讨了计算机断层扫描“辐射事件”的趋势，并提出了改进策略。
在对英格兰北部一个多站点国民健康服务信托基金内的辐射事件进行的纵向评估中，采用了回顾性混合方法。在信托基金层面查询DATIX，以识别2015年1月1日至2018年12月31日期间计算机断层扫描部门与辐射事件相关的所有记录。
在4年的审查期内，该信托基金共进行了159,596次检查，共记录了133起事件。其中包括42.1%（n = 56）的辐射事件、43.6%（n = 58）的未遂事件以及14.3%（n = 19）因造影剂外渗导致的重复扫描事件。报告的辐射事件发生率为0.08%。这些数据表明每千例中约有1起事件。大多数事件采用“系统方法”进行调查，报告突出了为试图防止事件再次发生而采取的相关行动。从根本原因分析记录中收集的定性数据显示了与促成因素、进行的事件分析以及整体学习相关的主题。
计算机断层扫描部门需要专注于系统方法而非“个人方法”，以确定可提高效率的领域。工作人员应乐于讨论他们遇到的系统低效问题，并可能突出管理层未意识到的问题。应鼓励报告所有类型的事件，包括未遂事件，以营造开放的文化并扩大学习。
