An x-ray was being taken of the patient’s lungs. When the radiographers came from the imaging room back to the control booth, the patient transporter triggered the imaging with the intention of helping. The situation did not result in any additional radiation exposure for the workers, and the imaging of the patient was technically successful.
Incorrect operation of the patient transporter was discussed internally with the persons responsible for patient transport and in the x-ray department meeting. The undertaking submitted a radiation deviation report and a patient safety report on the matter.
A hospital orderly received a radiation-emitting item (technetium generator), although the orderly does not have the rights to do so. Only the personnel of the nuclear medicine unit may receive items containing radioactive materials. Fortunately, the generator was left in a locked room in the isotope laboratory, so there was no danger.
Similar incidents are prevented by re-training hospital orderlies. The transport company was contacted and it was discussed with them who can receive a parcel. Written instructions on the delivery and reception of parcels are drawn up for the door of the nuclear medicine unit. In addition, the hospital security manager is contacted about the fact that the hospital orderly has allowed an external person to enter the premises of the nuclear medicine unit while the unit is closed.
The patient was undergoing full-body (head-to-toe) PET/CT imaging. The equipment's imaging data collection computer went into a fault state in the middle of the patient's imaging, and the imaging had to be interrupted.
The PET imaging nurse informed the physicist and maintenance was requested. The equipment maintenance personnel ran the entire equipment down. This takes a long time, so the patient could not be imaged again as the delay in the schedule would also have prevented the next four patients from being imaged. After the PET/CT equipment was ran down, the equipment functioned normally and other patients were imaged on schedule. The physicist and the radiographer tried to make images of the data afterwards, but the only the head area data was stored, so the nuclear medicine physician ordered the patient to be imaged again.
The reason for the radiation safety deviation was the failure of the PET imaging data collection computer. Due to the fault, the patient's imaging had to be repeated and the patient received an additional effective dose of 10.5 mSv. After the incident, the unit contacted the equipment manufacturer through the hospital's equipment maintenance, where the deviation is being investigated. If a fault is detected in the computer, the equipment manufacturer will repair it as warranty service.
A planning image of the patient’s spine and pelvic region was requested for radiotherapy dose planning, and the patient was imaged in a CT simulator in accordance with this request. After the imaging, it was revealed during the interview that the patient had received radiotherapy in another hospital two months earlier. The patient's texts or information from another hospital did not mention the radiotherapy received. After the imaging, the radiotherapist was informed of the patient having received radiotherapy in another hospital. The physician promised to look into the matter. According to the clarification, the patient had received radiotherapy for the same areas where it was planned to be given in the patient’s own hospital. The patient accumulated additional radiation dose corresponding to the planning image (effective dose 31.5 mSv). The planned radiotherapy was cancelled and a deviation report was submitted.
The reasons for the incident were the interruption in the exchange of information and possible misunderstandings along the patient's abnormal treatment path. The patient had an abnormal treatment path as the patient was treated in another hospital due to a drug trial. At the patient’s own hospital, it was not known that the patient had received radiotherapy elsewhere. Before the dose planning imaging, no indication on the patient having already received treatment was noticed. From the point of view of initiating radiotherapy, a near miss situation arose in this case.
The deviation report was discussed at an internal meeting of the radiotherapy unit. It was noted at the meeting that questions about old treatments must be asked at the physician's appointment and during interviews in connection with the planning imaging. As an additional measure, it was checked that the patient's interview form contains a section asking about previous treatments. This will ensure that the matter will be clarified at least at that point of the patient's treatment path.
In the future, the workflow will be modified so that in contrast medium imaging previous treatments are asked at the same time when it is asked whether the patient has reacted to the use of contrast medium previously. In similar cases, this would also avoid exposure to unnecessary CT imaging. In addition to the in-house processing of the matter, the adverse event was also reported to the Quality Manager of the other hospital. This Quality Manager processed the matter according to the unit's own practices.
During the hospital's evening shift, a small child had come for an x-ray examination of the abdominal area with her pregnant mother. However, the child did not stay still for the examination, so the two radiographers held the child in the correct position during the examination. Since there were only two radiographers on duty, the patient's mother triggered the imaging under the instructions. The next day, the radiographers realized that they had made a mistake. However, there was no additional exposure caused by the deviation, as the patient's comforter was in a different room during the imaging and the radiographers wore radiation shields.
The deviation was discussed with the radiographers and at the unit meeting. The reasons for the situation were hurry and the change of shift. For the future, the personnel will be informed of practices related to radiation safety so that a similar situation does not occur.
The patient underwent a skeletal scintigraphy with a radiopharmaceutical preparation. After the imaging, the activity was approximately 447 MBq, of which approximately 152 MBq was excreted in urine. The patient's urinary catheter bag was emptied prior to the imaging by the patient or the patient’s relative, and the drainage valve at the bottom of the bag was left open. After the examination, the nurse went to help the patient to get up from the examination table and lifted the urinary catheter bag, whereby radiant urine flew onto the nurse’s pants (approximately 2.9–3.5 MBq) and socks (approximately 1.0–1.6 MBq). The nurse took a shower and changed the clothes. The nurse was exposed to a small amount of additional radiation.
The examination table area was cleaned. At the front of the nurse's pants, there was an approximately palm-sized spot of urine. The radiation of the trousers was 5 µSv/h measured at a distance of 10 centimetres. The radiation of the sock was 2 µSv/h. The nurse was exposed to the radiation for approximately 15 minutes until the nurse took a shower and changed the clothes. After the shower, there was no noticeable radiation on the skin. Radiation waste and radiating clothing were placed in a lead-lined container and treated in the usual way after the half-life. The effective dose of the nurse, even when well overestimated, was no more than 2 µSv, which corresponds to 3–12 hours of background radiation.
In the future, everyone emptying a urinary catheter bag must remember to carefully close the drainage valve. The induction instruction is supplemented with a statement that the position of the urinary catheter bag valve is checked before moving the bag.
The radiographer went to the imaging room after the CT scout view to calm down a patient suffering from claustrophobia. The radiographer taking the image did not check the situation in the imaging room, but started the imaging while the colleague was still in the imaging room and the door was open. The radiographer taking the image noticed the situation immediately and interrupted the imaging. The equipment was able to take approximately 5 cross-sectional images. There were no people near the door. When the colleague left the imaging room and the door was closed, the imaging was normally continued and completed. The patient did not receive any additional radiation.
The radiographer was exposed to an effective dose of up to 13 µSv. The cause of the deviation was the stressful situation, hurry and a general chaos. The patient was afraid and the patient’s speech was difficult to understand, so the nurse had exceptionally gone to the imaging room to calm the patient down while the actual imaging was planned. There was a lack of communication between the colleagues.
The patient was ordered two CT scans: periradicular infiltration and lumbar spine CT. Lumbar spine CT was supposed to be taken after the periradicular infiltration, but a confusion in secretarial work and possibly a communication problem between computer systems led to a situation in which the lumbar spine CT was taken at the time reserved for the periradicular infiltration. The referral seen by the radiographer on the CT scanner had not given reason to doubt the timing of the examination, and the radiographer performed the examination normally.
Later, the radiographer who was taking the CT scan had heard that the case was being investigated at the x-ray unit. As a result, the radiographer made an internal radiation safety deviation report, which brought the case to the attention of the Radiation Safety officer. The patient is estimated to have received approximately 19 mSv of additional radiation exposure.
The matter was discussed with the secretary who handled the patient's examination appointments. The secretary was reminded of the correct procedure if there is any ambiguity in the appointment of the patient's examinations between different information systems. The case has been reported to the immediate supervisor of the secretaries and the supervisor has been asked to review what has happened and to go through the correct operating methods when booking appointments together with the secretaries who book appointments. The patient has been informed of being subjected to an unnecessary examination. The patient has been rescheduled for periradicular infiltration.
In the radiology unit of the hospital, a radiation safety deviation occurred in the health care CT scan. The radiographer chose a native imaging program even though the imaging was requested with contrast medium. Due to incorrect selection of the imaging program, the images had to be re-taken. As a result of the re-scan, the patient received an additional exposure of approximately 16.4 mSv.
The situation was addressed through interviews with employees about the reasons for the deviation. The deviation was due to human error and lack of communication at the workstation. The incident was discussed with the radiographer. In the future, communication will be improved so that similar situations can be prevented.
During the patient's CT scan in the radiology unit, the patient was exposed to a larger amount of radiation than planned as the wrong imaging program was selected. The radiographer chose the wrong imaging program which had three phases, of which only one was necessary. The effective dose due to unplanned medical exposure to the patient was 12.2 mSv.
The reasons for the deviation were discussed with the employee involved in the situation. A human error occurred in the selection of the imaging program. The incident was discussed with the radiographer who performed the imaging, and the unit emphasizes the importance of finding out the correct imaging program also during on-call times in the future.
A patient undergoing two-field palliative radiotherapy (pelvis + thigh) received an additional dose of approximately 1 Gy for the other field (pelvis) during the first treatment. This was due to confusion about taking pre-treatment check-up images between the radiographer manually positioning the patient and the other who performs the treatment.
A patient safety incident report was prepared at the hospital and the importance of check-up images after manual transfers has been discussed with the employees. The patient and the patient's relatives were informed of what had happened and the extra dose for the first treatment was taken into account during the second treatment. The total dose received by the patient was not exceeded.
The patient received radiotherapy for a benign tumour in the brain region. The patient had their last confirmed menstrual period about two weeks before the radiation oncologist's appointment. At that time, the patient had been instructed not to attempt to become pregnant during radiotherapy and to start contraception. The patient had followed these instructions since that day.
Immediately after radiotherapy (2.5 weeks after the appointment with the radiation oncologist), the patient reported that she was pregnant. The hospital immediately carried out a uterine dose estimate based on the patient's radiotherapy plan. The result of this measurement was 25 mGy for the entire radiotherapy period.
An embryonic exposure assessment was performed for the patient receiving radiotherapy and it was reported that, at this exposure level, the risk to the developing child from radiation is negligible. The patient confirmed that she remembered the doctor's instructions on how to avoid becoming pregnant during radiotherapy. A pregnancy test taken at the beginning of the radiotherapy period would probably not have revealed the pregnancy that had just begun.
The nurse went to medicate a patient during a procedure without personal radiation shields. X-ray images were taken during the procedure when the nurse was next to the patient. The nurse was in the imaging room for about 8 seconds, of which about 5 seconds the nurse was next to the patient. The dose estimate was calculated to be less than 2 µSv. The incident was due to negligence and the employee was unable to provide an explanation for what happened.
At the hospital, a CT-examination of the patient's body was carried out. After the scan, the device did not reconstruct the images and the patient had to be scanned again with another CT device in the hospital. The additional scan caused an effective dose of approximately 21 mSv to the patient. The equipment supplier was contacted about the incident, and it turned out that the image reconstrction hardware on the device was broken and the reconstruction of the images was therefore unsuccessful. A radiation safety deviation was reported in accordance with the hospital's instructions and the incident was processed in the unit.
The patient underwent a CT scan intended for another patient (a dual-phase liver scan and follow-up scans). Two patients had almost identical last names, and the patient had not been identified prior to the scan in accordance with the instructions.
The patient received a radiation dose of about 15.5 mSv from the unnecessary examination. The incident was discussed in the operator's department meeting, and the personnel was reminded of the patient identification procedures.
The control panel frame of the intraoral x-ray device was broken and the button for subjecting to radiation was pressed to the bottom. As a result, the x-ray equipment started taking images of itself as soon as the equipment was switched on. This happened four times before the personnel realized what was going on. After this, the use of the x-ray equipment was discontinued.
The incident caused additional exposure to the dentist, as the dentist's feet were exposed twice to a direct radiation beam. The patient in the treatment room was also exposed to scattered radiation. The radiation dose to the dentist was estimated to be less than 0.02 mSv. The maintenance service replaced the broken part of the x-ray equipment, and the operating condition of the equipment was checked before commissioning. The notifier has also made an incident report to Fimea.
In order to prevent similar incidents in the future, the matter was handled internally and the mechanical testing of the equipment is part of quality assurance before treatment.
A pregnant patient underwent an abdominal CT-examination. At first, attempts were made to MRI scan the patient, but the first images showed artifacts probably due to explosive fragments. After the first imaging attempt, the patient was assessed to be incompatible with the MRI scan. However, in a later review, an MRI examination was considered possible. The estimated radiation dose to the foetus was 13.5 mSv.
As a result of the incident, employees were interviewed for reasons that led to the deviation. The radiation safety deviation was caused by problems in the information exchange between the imaging unit and the units treating the patient. In order to prevent similar situations in the future, the patient's magnetic compatibility assessment process and its information flow, especially during on-call examinations, are monitored. Necessary changes will also be made to prevent gaps in the flow of information.
In the hospital, the patient was scanned twice with CT equipment as, during the first scan, the contrast media tube was accidently not attached to the cannula and the scan was performed without contrast media. The patient received an additional radiation dose of approximately 12.5 mSv.
The human error of the nurse was discussed with the personnel at the department meeting, and the employees were reminded to pay attention to the preparation of the patient even in the middle of busy times.
In the radiotherapy unit, the patient was prescribed radiotherapy on pain in three different metastases. One of the targets was a metastasis on the femur. However, the target area of the femur was segmented on the wrong leg. The target in question was prescribed radiotherapy with fractionation of 5*4 Gy. The treatment plan in question reached the implementation stage for the first two fractions before it was discovered that the treatment was drawn on and targeted at the wrong leg. As a result, this healthy femoral section was treated with 2*4 Gy in consecutive days. The treatment plan was rapid pain management of two opposing fields. In addition to the femur, the tissues in this treatment area are mainly muscles, fat, lymph nodes and skin.
Upon detection of the error, the situation was immediately assessed by a multi-professional team. The physician who treated the patient reviewed the case with the patient, and a more detailed investigation of the case was initiated within the hospital. On the basis of the initial evaluation, the physicians started monitoring for any immediate side effects (such as redness or swelling of the skin). The risk of long-term adverse effects in this case was estimated to be extremely low. According to the chief physician of radiotherapy, it is likely that the patient will not suffer significant adverse effects due to the treatment error, taking into account the patient's advanced age, the spread of the cancer and the nature of the disease. Considering the dose received and the small treatment target, acute adverse reactions such as lymphoedema and anaemia are unlikely.
According to a more detailed study carried out by the hospital, the radiation oncologist had used diagnostic CT scans in drawing the treatment targets. In the CT simulation image used for radiotherapy planning, the patient was imaged in a different position compared to diagnostic CT scans due to the feasibility of radiotherapy. When the physician had drawn the target area on the CT simulation image, the physician had accidently drawn it on the wrong leg. The physicists performed treatment planning on a CT simulation image drawn by the doctor. This is why the plan was made for the wrong thigh. Eventually, the physician approved the plan for treatment, and the radiographers began radiotherapy as planned. The radiographers and physicists noticed the target on the wrong thigh when they looked at the entries after the second fraction.
In order to prevent similar cases, the clinic physicians were reminded that the CT simulation image is always the official planning image for radiotherapy. Even if the physician uses other images, it should always be ensured that the radiotherapy target is correctly drawn on the CT simulation image. After the incident, different treatment positions and how they should be recorded in the systems were reviewed with all occupational groups. In addition, the review of the different stages of the radiotherapy chain (within the professional groups as well as in terms of the performers of the next stage) and the possibility for the physician to check that the treatment plan and the target are correct and optimal at the time of approval of the treatment were also reviewed.
A 1.1 GBq capsule of radioactive iodine was ordered for the hospital's radiotherapy unit. The employee of the transport company who brought the shipment left the package in the waiting room chair of the radiotherapy unit while the employee left to look for the receiver of the shipment. The hospital had given the delivery service provider the orderer's telephone number and instructed them to call if the recipient was not present at the time of delivery. For some reason, however, the courier left the package unattended in the waiting room instead of calling the recipient to come and pick it up.
The near miss situation did not cause any additional exposure to the employees or the population, as the source was properly packaged. In order to prevent similar incidents, the hospital made a complaint to the transport company and instructed the driver in the correct procedure.
A radiographer student entered the CT scan room during the heating and calibration of the equipment. The student stayed in the room for approximately 20 seconds. The incident was due to human error, as the student had received a normal orientation to the use of the equipment. The effective dose caused to the student by the incident was estimated to be less than 0.04 mSv. In the future, the hospital will provide more information about radiation during heating and calibration in the imaging room.
The patient underwent a CT scan of the heart and aorta. During the examination, the radiographers inadvertently placed the scout image tracking the contrast medium and starting the scan in an anatomically inappropriate place, due to which the contrast medium administration was not sufficient during the scan.
Due to this error, the examination had to be repeated under the guidance of a radiologist. Due to the re-scan, the patient received an additional effective dose of 12.3 mSv. The instructions will be specified to make the selection of the scout image clearer, and it will also be verified from the radiologist, if necessary.
An extensive CT scan of the body with contrast medium was performed on the patient. After the scan, the radiographers noticed that the contrast media tube had leaked from the connection point of the tubes during the scan and some of the contrast medium had spilled on the floor. The radiologist looked at the images and estimated that the contrast enhancement was not sufficient, so the scan had to be repeated. The patient received an additional effective dose of 20.6 mSv.
The reason for the incident remained unclear. The contrast media tube was not saved, and it is not clear whether the contrast media tube was poorly attached or if there was something wrong with the tube. The employees were instructed to assemble the contrast media tubing more carefully and, in the event of an abnormal event, to save the equipment for possible further investigation.