The Meeting held at the International Atomic Energy Agency (IAEA)’s Headquarters in Vienna, Austria, from 6 to 8 March 2017 gave Member States, international organizations and professional societies an opportunity to exchange information on methods for investigation, reporting and prevention of unintended and accidental exposure in diagnostic radiology and interventional procedures, as required by the International Basic Safety Standard (IAEA Safety Standards Series No. GSR Part 3). The need for improving primary prevention of medical radiation incidents and accidents was highlighted in the Bonn Call for Action by the IAEA and WHO. This is linked with the action for strengthening the radiation safety culture in health care.
The meeting was attended by 52 participants from 25 countries including radiologists, medical physicists, radiation technologists, and regulators as well as equipment manufacturers. It was attended by representatives from WHO, UNSCEAR, ISR, ISRRT, IOMP, Image Gently Alliance, DITTA, HERCA, CRCPD, ESR, EFOMP, EFRS, as well as a range of national organisations and regulatory authorities.
A growing number of deterministic injuries resulting from interventional procedures are being reported. Some of these may result from poor technique, but others while not intended could be difficult to avoid because of procedure complexity. Managing skin doses in interventional procedures and CT require hospitals to identify procedures that have a high potential to cause injury and ensure equipment settings are satisfactory and review protocols periodically. Training in techniques and radiation protection for cardiologists, surgeons and other clinicians, as well as radiologists helps to avoid these practices. Protocols should be available which take account of patient size and contain alert and trigger levels set in terms of the displayed quantities. Trigger levels should be set above which the patient would be informed and followed-up, and for external reporting of the exposure.
Unintended and accidental medical exposures may occur with all types of imaging procedure, some of them involving children and pregnant patient. Although health consequences are minimal in the majority of cases, proper investigation, and implementation of changes can avoid similar errors being made in the future. Grouping incidents into categories can help in deciding on the appropriate investigation route. Follow-up should look at remedial actions, to see what improvement could be made. All staff groups should collaborate in the process. Incident data should be kept at hospital level and should be available to the general manager, and disseminated through safety committees. Systems should be in place for follow-up and implementation of changes to avoid recurrence of similar incidents.
A large scale gathering of events is beneficial in disseminating lessons learnt nationally and internationally. This could be done through professional bodies, a regulatory body, or for high skin doses through SAFRAD, the web-based IAEA reporting system. Regulators may need to be informed of events that are indicative of demonstrable harm to the individual(s), events that involve vulnerable groups (e.g. pregnant individuals) and events that are of lesser potential for harm, but are indicative of safety culture failings. Regulatory bodies need to establish their response policy, adopting a graded approach and reporting criteria which take into consideration the resources and capacity of the regulatory body. The regulatory body should take all reports seriously, respond accordingly, not impose unnecessary burdens on institutions, and respect confidentiality.
The meeting concluded with recommendations that the IAEA could usefully provide training material on managing unintended and accidental exposures in radiology.