Human Factors in Radiation Incidents

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.

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.