Incidents and Investigations

Question 1

What is an accidental exposure?

Answer 1

No exposure was intended

Question 2

What is an unintended exposure?

Answer 2

Exposure was intended but the wrong exposure was given

Question 3

What is SAUE?

Answer 3

Significant Accidental and Unintended Exposure.

Question 4

What are examples of accidental exposures?

Answer 4

Procedural errors:
- Mistaken identity
- Issues with referral

Question 5

What are examples of unintended exposures?

Answer 5

• Forgotten bolus
• Wrong field size
• Wrong energy
• Machine calibration
• Incorrect shift/imaging match
• 6 fractions delivered rather than 5
• geographical miss (total or partial)

Question 6

When don’t you have to report an incident?

Answer 6

If no mistakes were made, e.g. repeat exposures with no procedural, hum, systematic or equipment errors.
- Patient coughed
- Bladder to full
- Patient didn’t know they were pregnant

Question 7

Why might you report an incident even if it is not reportable?

Answer 7

To learn from situations

Question 8

What is CSAUE?

Answer 8

Clinically SAUE, all must be reported, even if it does not meet the notification criteria.

Question 9

Within what timescale should incidents be reported?

Answer 9

2 weeks

Question 10

What are the IR(ME)R17 investigation requirements?

Answer 10

What happened
Estimated dose
Root cause analysis
Trends
Duty of candour
Inform Referrer and Practitioner
Determine clinical impact/harm to patient
Determine whether corrective measures have been implemented
Has learning been shared?