Recommendations for radiographers and radiation therapists drawn from an analysis of errors on Australian Radiation Incident Registers

INTRODUCTION The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) collect reported incidents for inclusion in the Australian Radiation Incident Register (ARIR), a database of radiation incident reports that occur within Australia. While the information on previous radiation incidents is available, there is little information on the lessons that can be learned from those past incidents to help prevent the same errors reoccurring. The aims of the study were to investigate what radiation incident registers are publicly available in Australia and to utilise the information contained within the ARIR and any other state or territory radiation protection authority registers to make recommendations for radiographers and radiation therapists to prevent future adverse events. METHODS A search was conducted to locate what radiation incident registers within Australia were available to the public. All adverse events from 2003 to 2014 were compiled into a spreadsheet for analysis. An error-type classification taxonomy was used to classify the adverse events. Conclusions were drawn from the determined causes to make recommendations to change work practices in an attempt to prevent similar adverse events reoccurring. RESULTS Incident registers were located from New South Wales, South Australia, Tasmania, Victoria and Western Australia. Radiography represented 76% (243) of the adverse events. A vast majority of the incidents were a failure to comply with time-out protocols (77%, 248). CONCLUSION There are several radiation adverse event registers publicly available to utilise in Australia. All departments need to adopt and strictly adhere to time-out protocols. This in conjunction with the other recommendations in this article has the potential to dramatically reduce radiation adverse events.