Podcast
Questions and Answers
What is a radiation incident?
What is a radiation incident?
Which of the following is NOT considered a patient safety incident?
Which of the following is NOT considered a patient safety incident?
What defines a 'near miss' in incident reporting?
What defines a 'near miss' in incident reporting?
Which of the following factors is most likely to contribute to incidents in healthcare settings?
Which of the following factors is most likely to contribute to incidents in healthcare settings?
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Which example best represents a 'never event'?
Which example best represents a 'never event'?
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What is a key benefit of reflecting on incidents?
What is a key benefit of reflecting on incidents?
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Which of the following is important when dealing with incidents?
Which of the following is important when dealing with incidents?
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What should you do if you are not comfortable with a task?
What should you do if you are not comfortable with a task?
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Why is it important to be open and honest during incidents?
Why is it important to be open and honest during incidents?
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What plays a significant role in personal resilience during challenging situations?
What plays a significant role in personal resilience during challenging situations?
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What should be done with incidents that occur in the x-ray room?
What should be done with incidents that occur in the x-ray room?
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Which of the following is a disadvantage of using an electronic reporting system like DATIX?
Which of the following is a disadvantage of using an electronic reporting system like DATIX?
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What information should an incident form include?
What information should an incident form include?
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Why is it important to report even near misses?
Why is it important to report even near misses?
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To whom must certain incidents be reported at specific doses or circumstances?
To whom must certain incidents be reported at specific doses or circumstances?
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What is a key learning outcome regarding human factors in radiation incidents?
What is a key learning outcome regarding human factors in radiation incidents?
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Which model is referenced in understanding why mistakes happen in radiation incidents?
Which model is referenced in understanding why mistakes happen in radiation incidents?
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What is one of the common approaches to reported human factors in radiation incidents?
What is one of the common approaches to reported human factors in radiation incidents?
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In the context of diagnostic imaging, what must radiographers understand about their responsibilities?
In the context of diagnostic imaging, what must radiographers understand about their responsibilities?
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What should be considered when completing a complex task related to radiation safety?
What should be considered when completing a complex task related to radiation safety?
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What is the primary focus of human factors ergonomics?
What is the primary focus of human factors ergonomics?
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What does the Swiss Cheese Model represent?
What does the Swiss Cheese Model represent?
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What is a workaround in a system context?
What is a workaround in a system context?
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What is the primary consequence of the person approach to incidents?
What is the primary consequence of the person approach to incidents?
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What is the most common error type in diagnostic imaging notifications?
What is the most common error type in diagnostic imaging notifications?
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What was the percentage of incorrect patient referrals for diagnostic imaging in 2020/21?
What was the percentage of incorrect patient referrals for diagnostic imaging in 2020/21?
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Under which conditions are humans more likely to make mistakes?
Under which conditions are humans more likely to make mistakes?
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What is the goal of analyzing a system after an incident occurs?
What is the goal of analyzing a system after an incident occurs?
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What is a primary aim of the multi-disciplinary team (MDT) meeting during an incident investigation?
What is a primary aim of the multi-disciplinary team (MDT) meeting during an incident investigation?
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What should a student do first after being involved in an incident?
What should a student do first after being involved in an incident?
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What can lead to the need for a workaround in a system?
What can lead to the need for a workaround in a system?
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Which imaging modality accounted for the highest proportion of notifications?
Which imaging modality accounted for the highest proportion of notifications?
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Why is it ineffective to dismiss an employee after an incident?
Why is it ineffective to dismiss an employee after an incident?
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What will happen during the meeting between the staff at UOB and clinical representatives after an incident?
What will happen during the meeting between the staff at UOB and clinical representatives after an incident?
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What is a crucial component for learning from incidents?
What is a crucial component for learning from incidents?
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What role does a Personal Academic Tutor (PAT) play after a student incident?
What role does a Personal Academic Tutor (PAT) play after a student incident?
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Study Notes
Human Factors in Radiation Incidents
- This presentation discusses human factors in radiation incidents.
- Learning outcomes include applying radiation protection principles in diagnostic imaging and understanding ionising radiation regulations and radiographer responsibilities.
- Session outcomes include introducing radiation incidents, accepting mistakes, understanding different incident types, human factors, how incidents are investigated, and university incident policy.
Why Mistakes Happen
- Mistakes in complex tasks are often caused by numerous factors.
- Tiredness, stress, pressure, and poor leadership are some causes.
- Individual circumstances, such as mental health issues (anxiety and depression), insufficient education, and training can contribute.
What is a Radiation Incident?
- A radiation incident occurs when a mistake leads to more radiation exposure for a patient than intended.
- Examples include performing an X-ray on the wrong limb, performing a CT scan on the wrong patient, or performing an X-ray that has already been done.
Other Types of Incidents
- Patient safety incidents involve a patient becoming unwell (seizure, loss of airway, or injury).
- Staff radiation incidents occur when staff are accidentally irradiated.
- Extravasation incidents happen when contrast leaks into surrounding tissues.
- Never events are serious incidents such as surgically removing the wrong limb.
Near Misses
- Near misses are incidents that almost happen but do not.
- They should still be reported and investigated.
- Learning from these near misses can help to prevent incidents.
What are Human Factors?
- Human factors are how humans are affected by things like teamwork, technology, environmental factors, and organisational factors.
- Human nature is prone to mistakes, especially under pressure or if tired or dehydrated.
- Factors like the number of clicks necessary in a computer task could lead to errors.
Swiss Cheese Model
- The Swiss cheese model illustrates how systems have flaws that can align to cause errors.
- Individual flaws in a system may not lead to an incident unless several flaws align.
- This model helps explain that systems of work are never perfect but efforts should be made to find and close gaps.
Workarounds
- Workarounds are deviations from protocols to improve efficiency.
- While workarounds can improve efficiency they are not always planned, which can result in incidents.
- Effective processes should consider and have input from staff on whether workarounds may be required.
Person Approach
- The person approach often blames the individual or person for taking deviant action.
- Potential disciplinary or employment consequences follow.
- This approach potentially discourages reporting future incidents and may cause anxiety.
System Approach
- The system approach recognises that mistakes happen and aims to improve the system.
- It asks how the system or process can improve.
- It avoids blaming individuals.
Blame Culture
- A blame culture creates fear and anxiety around reporting mistakes, which discourages individuals from reporting them.
- This leads to staff covering up mistakes or blaming each other.
- A blame culture can also lead to high staff turnover.
Open/Safe Culture
- An open and safe culture allows staff confidence in reporting incidents and near misses.
- The systems are regularly reviewed and adapted to improve work processes.
- This encourages a culture where mistakes are seen as opportunities for learning.
How Incidents are Reported
- Incidents should be reported locally and nationally.
- Local reports should occur within 24-48 hours.
- Timely reports facilitate investigation.
- National reporting to regulatory bodies, like the CQC, is required at certain thresholds.
Investigating Incidents
- Investigations involve gathering information from the original incident report.
- Further details and accounts may be sought.
- Multi-disciplinary teams frequently investigate issues, including medical physicists and radiographers, to identify systemic flaws.
- Investigating incidents enables improvements to systems and protocols.
Student Incident Policy
- Students are supported in incident reporting by their Personal Academic Tutor in conjunction with clinical staff and the University.
- Students are not required to attend staff meetings relating to these investigations.
Learning from Incidents
- Human error is common.
- Reflection is useful for learning from mistakes.
- Mistakes should be seen as opportunities to improve systems.
Tips for Dealing with Incidents
- Listen to and learn from others' experiences.
- Don't take actions you aren't comfortable with.
- Be open and honest.
- Self-reflection helps to learn.
Don't be Afraid to Speak Out
- Be confident to question if you are unsure or concerned.
- If something feels wrong, talk to the appropriate staff.
- If you are not comfortable speaking to clinical staff, involve your Personal Academic Tutor.
Summary
- Understand human factors.
- Why is acknowledging human factors crucial in radiation incidents?
- What should the focus be in an incident investigation?
Activity
- Reflect on two provided examples of incidents to determine the underlying factors.
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Description
This quiz explores the human factors that contribute to radiation incidents, emphasizing the importance of radiation protection principles and the responsibilities of radiographers. It covers the causes of mistakes in diagnostic imaging and the different types of incidents that can occur. Understanding and investigating these incidents is crucial for improving patient safety.
