Incidents and Investigations Flashcards
(38 cards)
What does SAUE stand for?
Significant Accidental or Unintended Exposure
What must the employer do if they belive a SAUE event has occured?
Report it to the CQC, following IRMER guidance.
What is an accidental exposure?
An exposure when no exposure of any kind was intended.
What is an unintended exposure?
An exposure when an exposure was intended, but the incorrect one was delivered.
What are the notification requirements for an accidental exposure in England?
Adult: 3 mSv effective dose or above
Child: 1 mSv effective dose or above
What are the notification requirements for an accidental exposure in Northern Ireland, Scotland, and Wales?
All, regardless of dose
Describe how it is determined whether an exposure is accidental or unexpected
What are the common causes of accidental exposures?
- Procedural errors
- Mistaken identity
- Referral issues
What is the notification requirement for an unintended exposure in imaging where the intended dose is less than 0.3 mSv?
Adult: 3 mSv effective dose or above
Child: 1 mSv effective dose or above
What is the notification requirement for an unintended exposure in imaging where the intended dose is between 0.3 and 2.5 mSv?
10 times more than intended
What is the notification requirement for an unintended exposure in imaging where the intended dose is between 2.5 and 10 mSv?
25 mSv or above
What is the notification requirement for an unintended exposure in imaging where the intended dose is more than 10 mSv?
2.5 or more times than intended
What is the notification requirement for an unintended radiotherapy over exposure?
1.1 times or more than intended over the whole course
1.2 times or more than intended in a single fraction
What is the notification requirement for an unintended radiotherapy under exposure?
0.9 times or less than intended over the whole course
What are the common causes of an unintended exposure?
- Forgotten bolus
- Wrong field size
- Wrong energy
- Machine calibration
- Incorrect shift/imaging match
What is the notification requirement for a total geographical miss in radiotherapy?
All total geographical misses, even for a single fration or significant part thereof
What is the notification requirement for a partial geographical miss in radiotherapy?
2.5 times the locally defined error margin AND when the guideline dose factors for the PTV and OARs are exceeded
When are notifications to the CQC not required?
If no mistake was made, however, it is still beneficial to report in these cases as they can guide future practice.
What does CSAUE stand for?
Clinically significant accidental or unintended exposure
What is a CSAUE event?
An accidental or unintended exposure that does not meet the SAUE criteria but has still made a significant clinical impact. These events must be reported.
Who provides guidance on CSAUE procedures?
The Royal College of Radiographers (RCR)
What is the definition of CSAUE in radiotherapy?
An event that has had, or is expected to have, a measurable effect on the patient’s tumour control, normal tissue toxicity, or quality of life. This includes exposures to ionising radiation that are significantly greater than justified.
What is the definition of CSAUE in imaging?
An event that has:
- Stochastic effects of: 0.1%
- Deterministic effects of: 0.5 Gy to heart, brain, or lens of eye; 5 Gy to skin, or 50 mGy to thyroid
- Psychological harm to the patient that requires intervention
How quickly must you inform the CQC following a SAUE or CSAUE event?
Within 2 weeks of discovering the incident
