Human Factors in Radiation Incidents 2023 PDF

Human factors in radiation incidents Helen Adamson 2023 1 Learning outcomes 4 – understand the importance of the ionising radiation 3 – apply the princ...

Human factors in radiation incidents Helen Adamson 2023 1 Learning outcomes 4 – understand the importance of the ionising radiation 3 – apply the principles of regulations and the radiation protection within the responsibilities of diagnostic imaging radiographers in assuring their environment implementation and actions to take where incidents occur 2  Session Outcomes Accept that Understand Introduce Understand what mistakes do different types of radiation incidents human factors are happen radiation incidents How incidents are Student incident The Swiss Cheese System vs person reported and policy for the model approach investigated university 3  Why do mistakes happen? THINK ABOUT TRYING TO COMPLETE A COMPLEX TASK – WHAT WOULD PREVENT YOU FROM DOING THIS WELL 4 Why do mistakes happen? Lots of reasons Never just one thing Tiredness Working under pressure and stress Poor leadership Personal circumstances (mental health such as anxiety and depression) Education and training Very rarely people do these on purpose 5 What is a radiation incident When a mistake results in more radiation than was intended for a patient Performing an x-ray on the wrong limb and then having to repeat it Performing a CT scan on the wrong patient Performing an x-ray when it had already been done 6 Not the only type of incident Patient safety incident – patient become unwell in department (seizure, loss of airway), falls and hurts themselves, receives skin tear from equipment Staff radiation incident – Staff member is accidentally irradiated, staff weren’t aware they were still in room, Extravasation incident – Most commonly happens CT, MR, IR whereby cannula is not in situ (in place) and so contrast leaks into surrounding tissues causing painful lump, risk of necrosis (death of tissue) Never events – These should NEVER happen, but they do, e.g. surgically removing the wrong limb 7 Near miss Nearly an incident but not Should still be reported in the same way Often not reported in practice YET there is so much learning here Often radiographer’s action/extra step has prevented the incident This action should be written int the system 8 What are human factors? The way we are as humans and how we are affected by different things Such as - teamwork, interactions with technology, environmental factors, organisational factors, culture Human nature – prone to making mistakes More likely if tired, stressed, working under pressure, dehydrated, Human factors ergonomics – study of these factors to better understand areas that might be more risk prone For example, the more clicks on a computer a task requires, the more likely we are to get something wrong 9  Swiss Cheese Model We create protocols/systems of work to be safe BUT we create them out of Swiss cheese Every one has flaws within it Just one flaw in one system is unlikely to cause harm If the flaws/hole align then this can result in incident Images taken from: James Reason Swiss Cheese Model. Source: BMJ, 2000 Mar 18:320(7237): 768-770 10 Workaround Definition = deviation from protocol in order to make the system more efficient Ultimately these are done because the system is not efficient enough But the deviation without planning is often present in incidents This doesn’t mean every workaround leads to an incident Ideally staff should be involved in protocols to proactively see if the systems are efficient and have input to prevent workarounds being needed EXAMPLE This Photo by Unknown Author is licensed under CC BY-SA-NC 11 Person approach Someone is to blame Deviant action taken by a person/human being Their sole responsibility and their sole fault Often led to disciplinary procedure being undertaken If you dismiss someone from their job does it stop that incident from happening again? 12 System approach Accepts that mistakes can happen and that they can happen to anyone who comes to the system Therefore most likely to be a system/process flaw System should be analysed to consider how can we prevent incident from occurring again Asking how can we make this system safer? How can we stop this same mistake from happening again? No blame on individuals 13 This Photo by Unknown Author is licensed under CC BY  BLAME CULTURE If one person is blamed for an incident/ mistake and receives disciplinary action then others will be scared to report their mistakes They may become anxious about making mistakes and become less efficient at their jobs (slow down due to the fear and double checking everything) could even result in loss of confidence Staff might cover up mistakes instead of reporting them out of fear Staff might start to blame each other instead of taking responsibility for their actions Multiple mistakes not being reported would mean that the systems of work are never changed, no actions taken to improve them, so the systems themselves become unsafe This Photo by Unknown Author is licensed under CC BY-NC Staff might leave due to the culture that now exists 14 Open/safe culture Staff are confident to report incidents and near misses Because of this the systems are regularly reviewed and necessary changes are made Staff are rewarded for reporting near misses and therefore become more active themselves in changing protocols and systems of work Staff are not afraid and therefore speak openly about mistakes they have made to new staff to help them avoid the same mistakes/incidents Staff are happy to discuss other more complex challenges in an open and honest way Staff morale is much higher and improves 15 staff retention This Photo by Unknown Author is licensed under CC BY  Activity – 10 mins to discuss Think about the following two incidents – what multiple things caused them to happen? (1) Rad does a left shoulder xray on patient, referral states left shoulder and when rad positions left shoulder patient complies with this. Referrer comes round afterwards to say it was a right shoulder. (2) Rad is about to do one x-ray and has read all the information and checked previous imaging but then another radiographer tells them there is an urgent patient to take in who has had a cardiac arrest that morning and they need to do it straight away. Rad takes the patient in and is hurrying to get it done quickly. In the x-ray room there is no computer to do the checks and therefore they proceed with a CXR but when they look afterwards the CXR was done an hour previously and the patient was in the waiting room, waiting for a CT chest 16  LOCALLY How Should be reported within 24/48 hours but ideally done ASAP – WHY? incidents are Electronic reporting system (e.g. DATIX) reported Advantages include audit trail & lead to investigate Disadvantages – some systems can take time to complete Incident form outlines important information regarding incident (date, time, what happened, why it happened, any NATIONALLY suggestions for how to prevent recurrence) At certain threshold doses or with certain Even near misses should be reported circumstances, incidents will need to be reported to the CQC (care quality commission). You can also voluntarily report them 17  CQC/IRMER Produce annual reports of national incidents across organisations within the UK Most common error type is where patient received an examination meant for another patient Accounts for 27% of all diagnostic imaging notifications However this has decreased from 36% in 2020/21 75 notifications where wrong patient had been referred for diagnostic imaging examinations Highest proportion of notifications from diagnostic imaging was from CT – 63% 18 How incidents are investigated Someone leads the investigation Gathers information from original incident report Might ask for further written accounts of what happened Some may be closed after these stages Multiple incidents might be discussed at a multi-disciplinary Team meeting (MDT) MDT = groups of different professions (many insights then) med physics, radiographer, radiologist, manager, team leader MDT should have good guidance for open discussion with no blame The aim is to identify why things went wrong and how can the systems be made safer Ultimately – how do we stop this incident from happening again? Actions may be taken, changes to protocols Learning should be shared across teams 19 What to do if you have an incident as student? Inform clinical supervisor or radiographer working with Inform your PAT Your PAT will help you to write a statement about what happened Important to write about how you were working before, during and after incident – as a student you should be supervised 20 21 Student incident policy PAT will support you PAT and staff at UOB will meet with clinical to discuss what happened – you will not attend this meeting Meeting will suggest actions or changes to processes Learning will be shared with clinical and UOB team 22 Learning from incidents Mistake do happen!! Human nature = not perfect We must learn from incidents Helps us to develop further knowledge, understanding, professionalism and skills Reflection is useful Speak to others Personal resilience Be open and honest 23 Tips for dealing with incidents Listen to others experiences of incidents they have had Do not ever do anything you do not feel comfortable to do Be open and honest when things do go wrong Be kind to yourself and reflect (even if uncomfortable to do so) as this is how you learn from mistakes 24 Don’t be afraid to speak out Talk to staff at the Don’t do anything if university/PAT if you’re Confidence to you are not happy to not comfortable to question do it (particularly as highlight to clinical student radiographers) staff Tell me – summary What are human factors? Why is it important we acknowledge them in radiation incidents? What should be the main focus of an incident investigation? 26 ANY QUESTIONS 27 SOCRATIVE QUIZ 28