Winter Katharina Stella, Schweden Monika, Brix Gunnar, Mille Erik
Generic aspects of medical radiation protection, Federal Office for Radiation Protection Neuherberg, Oberschleißheim, Germany.
Rofo. 2025 Feb;197(2):154-162. doi: 10.1055/a-2339-3684. Epub 2024 Sep 11.
In Germany, significant incidents must be reported to the competent authority since 12/31/2018 (section 108 Radiation Protection Ordinance (StrlSchV)). After assessment and evaluation of the reports, the competent authority submits the relevant information via a web-based reporting system (BeVoMed) to the Federal Office for Radiation Protection (BfS), which publishes the results derived therefrom. The present paper evaluates significant incidents related to X-ray exposures on humans.All reports on incidents in X-ray diagnostics and interventional radiology between 01/2019 and 10/2023, which were completed with detailed information until the reporting day (31/10/2023), were included. The following aspects were statistically evaluated: classification as an incident (section 1 subsection (22) StrlSchV), significance (section 108 StrSchV), classification to Annex 14 StrlSchV, assignment to the forms of care in the German healthcare system, and development of the reporting frequency over time. Furthermore, the content of the reports was systematically evaluated with regard to conspicuous clusters and typical problems.Until the reporting day, 383 reports (355 completed) were received. 252 reports (228 in X-ray diagnostics, 24 in interventional radiology) referred to significant incidents and were included in the detailed evaluation. Reporting frequency increased in X-ray diagnostics, whereas there was no trend in interventional radiology. Most of the significant incidents concerned examinations on an individual person (category I, criterion 2a or category II, criteria 2a and 3a) in the in-patient sector - especially in maximum care hospitals. Frequent errors concerned the inappropriate choice of parameters/protocols or were related to the administration of a contrast agent. Despite the overall positive trend, the establishment of awareness and error culture remains challenging. · In X-ray diagnostics, the reporting frequency of significant incidents increases.. · Most incidents concerned CT examinations in the in-patient sector.. · Main problems were selection of protocols/settings, contrast administration, and bolus-tracking.. · Uncertainties remain about the classification of an incident as significant and notifiable.. · Winter KS, Schweden M, Brix G et al. Significant incidents during X-ray exposures in humans - assessment and findings of the Federal Office for Radiation Protection. Rofo 2025; 197: 154-162.
自2018年12月31日起，在德国，重大事件必须向主管当局报告（《辐射防护条例》（StrlSchV）第108条）。在对报告进行评估和评价后，主管当局通过基于网络的报告系统（BeVoMed）向联邦辐射防护办公室（BfS）提交相关信息，该办公室公布由此得出的结果。本文评估了与人体X射线照射相关的重大事件。纳入了2019年1月至2023年10月期间X射线诊断和介入放射学领域所有事件的报告，这些报告在报告日（2023年10月31日）之前已填写详细信息。对以下方面进行了统计评估：事件分类（《辐射防护条例》第1节第（22）款）、重要性（《辐射防护条例》第108条）、《辐射防护条例》附件14分类、德国医疗保健系统中护理形式的分配以及报告频率随时间的变化。此外，还就明显的聚集情况和典型问题对报告内容进行了系统评估。截至报告日，共收到383份报告（355份已完成）。252份报告（X射线诊断领域228份，介入放射学领域24份）涉及重大事件，并纳入详细评估。X射线诊断领域的报告频率有所增加，而介入放射学领域则没有趋势。大多数重大事件涉及住院部门对个人的检查（第一类，标准2a或第二类，标准2a和3a）——尤其是在特级护理医院。常见错误涉及参数/方案选择不当或与造影剂给药有关。尽管总体呈积极趋势，但提高意识和建立错误文化仍然具有挑战性。·在X射线诊断中，重大事件的报告频率增加。·大多数事件涉及住院部门的CT检查。·主要问题是方案/设置选择、造影剂给药和团注追踪。·对于事件是否重大且应报告的分类仍存在不确定性。·温特KS、施维登M、布里克斯G等。人体X射线照射期间的重大事件——联邦辐射防护办公室的评估和发现。《德国放射学杂志》2025年；197:154 - 162。
