Template to Record Patient Radiation Incidents 2013
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Template to record Patient Radiation Incidents 2013
Please provide total number of incidents/near misses (which includes incidents already reported to the Medical Exposure Radiation Unit) for the period January to December 2013 (annually).
It is important to note that if you are submitting incident information for more than one hospital on a single reporting form please ensure that you list the hospital details for each hospital you are reporting figures for. This may apply to the larger hospitals that have responsibility for a smaller hospital.
Hospital Name:______Reference Number:______
Hospital Name:______
Categorisation by Modality(code for STARSweb, recording system used in public hospitals in brackets)* / Total Number of Patient Radiation Incidents (including near misses)
Speciality – Radiology / Actual / Near Miss
Radiology – General (9100)
CT(9300)
Nuclear Medicine/PET CT (9400)
Interventional Radiology/Fluoroscopy (9500)
Speciality – Radiotherapy
External Beam (9200)
Brachytherapy (G100)
* STARSweb code in brackets is relevant only to HSE public hospitals.
Incident Type / Number of Patient Radiation Incidents per type (Actual and Near Misses to be recorded separately)Actual / Near Miss
No dose intended/Incorrect patient < 1milliSievert (tba)
No dose intended/Incorrect patient > 1 milliSievert (D001)
Incorrect procedure (D002)
Incorrect Anatomy (D003)
Multiple exposures greater than intended * (D006)
Adult: > twice Diagnostic overexposure >10mSv or 20 times dose intended (D007)
Child: > twice Diagnostic overexposure > 3mSv or 15 times dose intended (D008)
Inadvertent Dose to foetus > 1mSv (D009)
Inadvertent Dose to Foetus <1mSv (tba)
Incorrect Radiopharmaceutical (D010)
Dose to the breastfed child over 1mSv (D011)
Therapeutic N Med - Administered activity different by 20% of intended (D012)
Therapeutic N Med - Administered activity different by 10% to 20% of intended (D013)
Therapeutic dose given instead of diagnostic dose e.g. radioiodine (D014)
Radiotherapy Dose or volume variation from the total prescribed ofless than 5% (tba)
Radiotherapy Dose or volume variation from the total prescribed - 5% to 10% (D018)
Radiotherapy Dose or volume variation from the total prescribed of greater than 10% (D015)
Radiotherapy Dose or volume variation from the fraction prescribed - 10% to 20 % (D017)
Radiotherapy Dose or volume variation from the fraction prescribed of greater than 20% (D016)
Inadvertent Deterministic effects (D021)
Dose given to carers without consent greater than medical council guidelines (D022)
Any other radiation exposure incident to patient (D023)
Please liaise with the Risk Management Team in your hospital to ensure that the patient radiation incidents reported on the form attached correlate with the incidents reported through your risk management systems (e.g. STARSweb/Clinical Indemnity Scheme for public hospitals), for the same time period.
Signed:______, Chair, Radiation Safety Committee
Signed:______, Risk Manager
Signed:______, CEO/Hospital Manager
Template to record Patient Radiation Incidents 2013
Please provide total number of incidents/near misses (which includes incidents already reported to the Medical Exposure Radiation Unit) for the period January to December 2013 (annually).
If the data submitted on this template includes more than one hospital please let us know by listing each hospital name below.
Hospital Name:______Reference Number:______