TEMPLATE FOR REPORT OF INVESTIGATION AND FINDINGS OF PATIENT RADIATION INCIDENT.

Additional information or local reports may also be attached as required.

Hospital: ______Reference: ______MERU reference:______

  1. Incident

Date of Incident: / Time of Incident: / Location of incident:
Patient age: / Patient sex: / M F / MERU Incident definition
What speciality was patient admitted under / referred from? / NEAR MISS?YES - NO -
Incident description: (Accurately describe, in chronological order, the relevant details of what happened leading up to, immediately before, during and after the incident and others involved):
How was the incident discovered, and by who?
  1. Investigation

Who led the investigation? / Who was on investigation team (include referring clinician where applicable)?
Was risk management involved in the investigation? / Y N 
Was a formal system /root cause analysis conducted? / Y N 
Briefly outline the methodology used by the investigation team:
Is there a written protocol on communication with the patient or open disclosure? / Y N 
Was it decided to communicate with patient and/or carers? / Y N 
If yes, what was the communication with the patient, including discussions and plans?
Was the communication with the patient consistent with the written protocol? / Y N 
Who else was consulted and informed during investigation (including referrer and practitioner in charge, other relevant staff)?
Was incident reported to regulatory bodies and Insurers (e.g., RPII, HSA, IMB, CIS, Serious Incident Management Team for HSE), please state which:
Is the investigation complete? / Y N 
If no, date for completion:
  1. Cause of Incident

From the findings of the investigation, what were the direct, indirect and root causes the incident? (refer to system analysis techniques for cause descriptions)
Which of these was identified as the main cause?
  1. Patient Radiation Dose

What was the Dose to the Patient in relation to that prescribed/ not prescribed: (as a total figure (mSv/mGy) and as a percentage greater than intended):
What are the consequences/clinical impact to the patient as a result of the incident?
If ongoing medical surveillance for the patient is required, has a plan been implemented? / Y N N/A 
  1. Recommendations and Actions

List any immediate action that wastaken to minimise harm to patient or recurrence for others:
What are the findings of the report and recommendations to prevent a similar incident occurring in future, including follow up actions with patients, staff and others?
List actions already taken (including the date):
List additional actions that must be taken and the timeframe for completion.
What is the likelihood of a similar incident occurring?
Was this investigation discussed at the Radiation Safety Committee or tabled for next meeting? / Y N 
What date is set for review of actions?
Any other information relevant to this report, e.g., what is the learning for this and/or other locations?
Person responsible for implementation of actions:
______ / Signed: / Relevant Practitioner
______ / Signed:
Referring Clinician, where applicable
______ / Signed: / CEO/Hospital Manager:
______ / Signed:
Chair, Radiation Safety Committee:
______ / Signed:
Reported completed by: / Role: / Email:
Signed: / Date: / Tel:

Please return signed copy to: Private and Confidential, Medical Exposure Radiation Quality Assurance and Verification Division, Health Service Executive, Room 4, 3rd floor, Stewarts Hospital, Palmerston, Dublin 20 – D20N292 or by email to: /