Learning from mistakes: incidents during radiation applications

A CT scan Source: Johnny Greig via Getty Images

Medical radiation applications are a permanent fixture of healthcare in Germany and are, on the whole, very safe. Despite high quality standards, however, it is possible for people to be unintentionally exposed to too much radiation during an examination or therapy. For example, this can happen if the radiation dose is exceeded in a computed tomography (CT) scan or if patients are mixed up.

This then constitutes a "significant incident" in the sense of radiation protection law and must be reported.

The Federal Office for Radiation Protection (BfS) has now published the report on significant incidents in medicine for Germany in 2021. The latest figures on reported incidents can be viewed online. BfS President Inge Paulini has taken the opportunity to call for transparency when it comes to handling possible errors: "Every report of a significant incident is important for patient safety and radiation protection. Every report contributes to ensuring and further developing the high standards of radiation applications in medicine."

Pseudonymised recording, scientific evaluation

Doctors in discussion Source: Robert Kneschke/Stock.adobe.com

Significant incidents are reported to the supervisory body of the respective federal state by the radiation protection officers of hospitals, practices and medical care centres. The authorities of the federal states evaluate the reported incidents, order the adoption of measures if necessary, and forward the evaluated reports electronically to the BfS in pseudonymised form – that is, so that the reports cannot be directly attributed. The BfS carries out an expert review of the reports and publishes the findings.

The objective is to avoid similar incidents in the future wherever possible.

Similar number of reports to the previous year

As of the reporting date in mid-July 2022, there had been 100 reports for 2021 – a similar number to the previous year, with about half of incidents taking place during treatment. Given the high overall numbers of examinations, however, the number of corresponding reports seems very low: in Germany, some 13 million CT scans are performed each year, and around 2 million examinations are performed each year in the field of nuclear medicine.

Based on estimates from a research project initiated by the BfS, there should have been significantly more reportable incidents during the period in question. This assumption particularly applies to the outpatient sector, from which only very occasional reports were received.

Inge Paulini

Joint steps for patient safety

Paulini calls on radiation protection officers from the outpatient and inpatient sectors to foster transparent handling of reportable incidents at their institutions: "The common goal is to further improve patient safety. To this end, we need an error culture that is jointly developed and supported by everyone who applies radiation to humans. Only in this way can we learn from incidents and make radiation applications even safer."