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Report highlights learnings from nuclear medicine incidents

2 February 2022

ARPANSA has finalised its annual report on radiation safety incidents using data collated from radiation regulators around the country. The report helps identify opportunities for improvement in the safe use of radiation particularly in the medical sector.

The new Australian Radiation Incident Register (ARIR) report provides a summary and analysis of incidents that occurred during 2020. The report includes a focus on workflows in nuclear medicine. Nuclear medicine accounted for 157 of the 803 incidents reported for 2020.

‘Ensuring the right patient gets the correct amount of the right radiopharmaceutical is a vital part of nuclear medicine’, said Mr Jim Scott, Chief Regulatory Officer at ARPANSA, ‘asking verification questions at the right time and organising your workspace can help prevent errors.’

Assessing the workflow or patient journey can help to identify areas for improvement. Examples from the report include reducing the number of vials in the workspace, the effective use of colour coding and placement, and the use of labels and computer scanning.

‘These incidents, while rare, highlight learnings from nuclear medicine incidents that can be applied in many different settings’, said Mr Scott.

‘Overall, we continue to see an increase in the number of incidents reported each year’, said Mr Scott, ‘this increase is likely due to improved reporting practices, rather than an increase in actual incidents.’

‘It is a reflection of good regulatory practice among hospitals, organisations and contributing states. Everyone can learn from each other’s experiences to ensure safe radiation use across Australia.’

Findings of the report include:

  • a total of 803 incidents reported – demonstrating better awareness of reporting
  • 529 of the reported incidents were in diagnostic radiology, with 157 in nuclear medicine, and 40 in radiotherapy
  • patients were exposed to less than 1 mSv of radiation in 47% of incidents
  • human error was identified as a factor in more than 65% of incidents
  • equipment failure or deficiencies accounted for 17% of incidents.

Information from the ARIR raises awareness on where, how and why incidents and events involving radiation occur, and shares strategies to prevent them.

Both the ARIR and this summary report play an important role in ensuring the ongoing safety of Australians using or receiving radiation.

Read more: ARIR annual summary reports.

A simplified example of a nuclear medicine workflow (view full-size workflow):

Workflow showing the journey for a patient receiving a scan