Hiqa inspectors highlight incident-reporting issues at CUH

ISSUES surrounding the reporting of incidents of medical exposure have been highlighted in a Hiqa report on the radiology department in CUH.

Inspectors were not satisfied that there was an appropriate system in place for recording and analysing potential incidents involving medical exposures.

All potential incidents should be recorded, so that the risk of potential harm to the patient is minimised by early risk-management actions. However, from speaking with staff across the radiotherapy team, inspectors found a lack of knowledge on the topic.

“They were not consistent in their definition of a potential incident or non-conformance… and therefore were not consistent on if and when such potential incidents were to be reported,” it was noted.

Inspectors also noted that “a significant number of incidents were not submitted within the timelines defined by Hiqa and therefore were not consistently meeting their regulatory requirements”.

This was due to staffing issues, according to the report, which states: “It was established that delays in reporting to Hiqa were often as a result of key personnel not being promptly available.”

Greater detail was also required in the investigation reports submitted, in order to provide adequate assurances that measures were in place to minimise the risk of incidents recurring.

The department’s internal monitoring was also a cause of concern for Hiqa, with issues discussed by a radiation safety committee (RSC) not reported to senior management.

The inspectors noted “significant gaps in the radiation protection governance reporting lines” and “limited evidence to show that the senior management team had adequate oversight of radiation protection matters”.

The RSC reported twice yearly to the Executive Quality and Safety Committee (EQSC), which in turn reported quarterly to an Executive Management Board (EMB) which was chaired by the CEO.

KEY MATTERS NOT DISCUSSED

However, although the RSC had met four times in the previous 12 months, from a review of RSC meeting minutes, inspectors saw that key matters of radiation protection were not discussed. Furthermore, a review of the minutes of the EQSC showed that the reports from the RSC had not been brought up.

Inspectors also requested the quarterly reports from the EQSC to the EMB for the previous 12 months, and were informed that none were available, as the EQSC had not reported to the board in this time. Though it was noted that “the radiation protection of service users attending for radiotherapy treatment was not an issue at the time of the inspection”, it said that “this was mainly due to the commitment of staff working in the department”.

The report also looks at how the hospital is going to become compliant with the regulations, and stated that the RSC meeting agenda has been revised to include the topics which inspectors noted were not being discussed.

The RSC will also no longer report to the EQSC, and now reports to the Clinical Effectiveness committee, the hospital said.

The Clinical Effectiveness committee receives the minutes of all RSC meetings and is informed of any matters for escalation or further action, and then escalates relevant matters to the EMB, who they report to monthly.

The CUH procedure for radiation incidents and near misses is also to be revised to include clear definitions on potential incidents or non-conformance, completion of investigation reports, and systems to be followed to ensure correct analysis of incidents.

Training for staff on changes to the current procedure is to be provided and supported by CUH’s quality & patient safety department, to ensure that all staff are clear on what to report and how.