The Care Quality Commission has published IR(ME)R annual report 2023/24, which is the summary of the year’s IR(ME)R inspections and notifications issued to employers.
Anyone with an IR(ME)R duty holder role, such as operators, practitioners, and referrers is encouraged to read the report, and employers should note the specific actions for employers to improve compliance.
The SoR has welcomed the annual report from the CQC in their capacity as the competent authority in England for the enforcement of The Ionising Radiation (Medical Exposure) Regulations 2017.
It offers a valuable insight into the current challenges and trends in non-compliance using analysis of significant accidental and unintended exposures notification data. Its value as the evidence base to underpin improvements in radiation safety education, training and policy development is unparallelled.
There are reassurances that can be taken from the report. The incidents notified to the enforcing authority represent a tiny percentage of the 45.5 million imaging tests undertaken between March 2023 and February 2024 by NHS services in England.
However, it is important to remember that there are many more incidents that occur every day that do not meet the threshold for notification as a significant accidental or unintended exposure.
The learning from this report can be applied to all reported and investigated incidents.
Key points to note from this year’s report are:
Notification
Where services that undertake high levels of activity do not report or report unusually low levels of incidents there are concerns about the adequacy of their ability to identify and appropriately manage incidents. Please see the guidance on When to investigate and notify the enforcing authority.
Patient Identification Failures
Poor patient identification procedures and inadequate systems to safeguard patients from accidental exposures have again been highlighted as a key source of error in diagnostic imaging pathways.
Failures to check identity continue to occur throughout the patient pathway from the referral to the exposure. This does not appear to be the case in radiotherapy.
In collaboration with SoR members, the four UK IR(ME)R regulators and the UK Health Security Agency (UKHSA), SoR published Preventing Patient Identification Incidents in Diagnostic Imaging, Nuclear Medicine and Radiotherapy – guiding principles for safe practice in the United Kingdom in 2022.
It is both disappointing and an area for concern that this is still the most common reason for accidental exposures. Further work is warranted to understand why these failures continue to occur.
Justification and authorisation
There is confusion around when an individual is justifying and authorising an exposure, and when they are authorising under guidelines issued by the IR(ME)R practitioner. To keep pace with advancing practice roles, it is important duty holders know the legal framework under which they are working.
To understand this more fully please register for the next webinar in our radiation protection series Justification and authorisation of exposures in diagnostic imaging, nuclear medicine and radiotherapy – whose role is it anyway?, on Tuesday 12 November at 7pm.
The SoR will use the opportunity of a free Q&A session during the webinar to understand the education, training and operational issues continuing to cause confusion.
The Diagnostic Radiographer as the entitled IR(ME)R Practitioner concerns the provision of adequate training for radiographers to be entitled as IR(ME)R practitioners.
Referrals by unregistered healthcare staff
Referrals outside scope of practice and referrals by unregistered healthcare staff continue to arise. Anyone working with ionising radiation must know the legal framework under which they practise and the limitations of their IR(ME)R entitlement.
The CQC recognises that it is not the sole responsibility of radiology staff to manage the governance of referrals and that all duty holders must know and manage their roles as a collaborative.
Paediatric over exposures
Paediatric over exposures are of particular concern in this year’s report. These were caused by a lack of training or familiarity with equipment and appropriate exposure factors and operators feeling rushed or being distracted.
Employers may find it helpful to read Principles of Safe Staffing for Radiography Leaders and SoR members can watch the recorded Safe Staffing Webinar to understand more about how to determine, and evidence the need for, an appropriately trained workforce.
Shortage of Medical Physics Experts
The report highlights the chronic shortage of medical physics experts and reiterates the importance of engaging their expertise in both the development of a business case and in the procurement and installation of new equipment.
SoR experiences member-reported operational and safety challenges when the medical physics team is engaged too late in this process. This increases the risk of significant unintended exposures.
Computed Tomography Services
As in previous years, most diagnostic errors (65 per cent) came from CT services. This is a slight increase on last year and while it reflects a healthy and open reporting culture, it should be considered a priority area for employers to ensure staff are receiving adequate education, training, and support.
Employers should ensure they are engaging an appropriate skills mix with the expertise required to manage these services safely. The SoR CT Advisory Group is developing guidance on competencies for radiographers working in CT.
Employers may find Developing CT workforce competencies: What knowledge and skills should we expect of an early career radiographer? a useful reference to support new professionals to develop the essential technical competencies expected of radiographers working in CT in the UK.
Plain film (projectional) radiography
This was the second most frequent area (25 per cent) of notification. Common errors included patients receiving an examination meant for someone else either because the wrong person was referred, or the wrong person was exposed. Operator errors made up 41 per cent of these followed by referrer errors (33 per cent).
Radiotherapy
In radiotherapy, a theme of human factors errors was reported with inconsistency in how these were managed. Where a systems approach was employed, it was considered more effective than where the error was attributed to individual fault.
There has been an expected decrease (10 per cent) in notifications in planning and verification imaging which is thought to be because of amended thresholds to reflect changes in treatment regimes. Treatment verification imaging was the most common source of errors.
Low staffing levels across all duty holder roles in radiotherapy and the risks associated with this were inconsistently understood and managed. Benchmarking staffing levels was seen as an effective measure in the development of business cases for additional staffing.
Extreme staffing shortages had led to a reduction of service provision and non-essential tasks.
Nuclear Medicine
Nuclear medicine notifications have increased by 66 per cent compared to last year. The majority of these came from diagnostic nuclear medicine and PET-CT or PET/MR studies. It is noted that hardware failures contributed to more notifications than previously.
The report will be reviewed by SoR Advisory Groups working with ionising radiation and by other relevant Society of Radiographers special interest groups. The groups will discuss the issues and determine where our members might seek additional guidance and support from the SoR radiation protection experts.
Professional officers will continue to collaborate with relevant organisations, such as the Royal College of Radiologists (RCR), UK Health Security Agency (UKHSA), British Institute of Radiology (BIR), Institute of Physics and Engineering in Medicine (IPEM), National Breast Imaging Academy and the British Nuclear Medicine Society, to ensure awareness is raised on where professional body support is available.
SoR continues to work closely with all four enforcing authorities for IR(ME)R in the UK. The valuable intelligence shared within these partnerships influences where we direct our resources to best support our members and the wider workforce.
We remain committed to driving initiatives that champion safe and caring environments in which UK radiographers feel supported and motivated to work.