Training activity information
Details
Investigate a patient overexposure including the advice on:
- Whether the exposure should be externally reported
- Shared learning from the incident
Type
Developmental training activity (DTA)
Evidence requirements
Evidence the activity has been undertaken by the trainee​.
Reflection on the activity at one or more time points after the event including learning from the activity and/or areas of the trainees practice for development.
An action plan to implement learning and/or to address skills or knowledge gaps identified.
Considerations
- Determining the cause of the overexposure
- Local and national guidance
- Requirements and process for external reporting and the regulators/documents to refer to
- Appropriate authorisation for reporting
- Preventative measures for future practice
- Lessons learned and future prevention
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What understanding of incident reporting procedures and the principles of shared learning are you expected to gain?
- How will this activity contribute to your ability to discuss the investigation of an incident involving radiation exposure to a patient?
- What are the key steps involved in investigating a patient overexposure incident?
- What criteria determine whether an overexposure should be externally reported to regulatory bodies?
- How can lessons learned from such incidents be effectively shared to prevent future occurrences?
- What considerations are important when advising on remedial actions and further reporting following a patient overexposure?
- Will you review relevant local protocols and national guidance on reporting radiation incidents?
- What information would typically be required to determine the severity and cause of a patient overexposure?
- Will you consider the principles of root cause analysis and how they might apply to this type of investigation?
- How will you approach formulating advice on shared learning from the incident to ensure it is constructive and promotes improvement?
In action
- Pay attention to your actions.
- How are you approaching the investigation of this overexposure incident? What steps are you taking to gather information?
- What decisions are you making as the investigation progresses (e.g., who to interview, what data to review, how to assess the severity of the overexposure)?
- What aspects of incident investigation and reporting criteria feel intuitive based on your understanding, and what requires more conscious referencing of protocols and regulations?
- How effective are your investigative steps in understanding the sequence of events leading to the overexposure and its potential consequences?
- Are you gathering the necessary information to determine reportability and identify learning points?
- What challenges are you facing during the investigation (e.g., incomplete records, conflicting accounts, difficulty in assessing the dose)?
- What can you learn about the practicalities of investigating overexposure incidents and determining appropriate actions (including reporting and shared learning) as you undertake this training activity?
- How does this investigation relate to your knowledge of radiation incidents, dose assessment, regulatory reporting requirements, and the importance of shared learning in preventing future occurrences?
- Are there alternative lines of inquiry or sources of information you could be considering if your initial investigation is not providing a clear picture?
- What support or guidance might you need in the moment regarding specific aspects of the investigation, dose assessment, or reporting procedures?
- Are you ensuring your investigation is conducted thoroughly, objectively, and in accordance with relevant protocols and your level of training?
On action
- What were the key details of the patient overexposure incident you investigated?
- What steps did you take to gather information and understand the sequence of events?
- What factors contributed to the overexposure?
- What were the relevant guidelines or regulations regarding external reporting of such incidents?
- What advice did you formulate regarding external reporting and shared learning?
- What did you learn about the process of investigating radiation overexposures?
- Did you develop or improve your understanding of the criteria for external reporting of radiation incidents?
- What did you learn about the importance of identifying and disseminating lessons learned from such events?
- How does this experience relate to maintaining patient safety and quality in radiation practice?
- What areas for continued development have been identified in your ability to investigate patient overexposures and provide appropriate advice?
- How will you apply this learning to contribute to incident prevention and management in the future?
- What actions or ‘next steps’ will you take to further develop your skills in incident investigation and reporting?
- What support or resources might you need to enhance your expertise in this area?
Beyond action
- Consider evaluating and re-evaluating your investigation of the patient overexposure.
- What were the key factors that led to the overexposure, and what advice did you formulate regarding external reporting and shared learning?
- Have you had any feedback on the effectiveness of the actions taken following your investigation?
- Compare this experience with contributing to the investigation of a radiation incident involving staff. What similarities and differences did you observe in the investigation processes and the considerations for external reporting and shared learning? What behaviours in incident investigation have you adopted by comparing these experiences?
- Revisit your notes, analysis, and any advice you provided. Have your understanding of reporting requirements and the principles of effective shared learning in radiation safety incidents evolved since then, perhaps through further training or reading? What aspects would you now approach differently?
- Discuss your investigation and recommendations with your training officer or senior colleagues. Have their insights or experiences with similar incidents broadened your understanding of best practices in incident management and learning?
- Recognise that investigating overexposures is critical for preventing future incidents and improving patient safety.
- How has this experience heightened your awareness of potential error pathways in radiation practice and the importance of robust safety systems?
- How has the process of advising on external reporting and shared learning developed your understanding of regulatory requirements and the principles of effective communication following an incident?
- Identify the transferable skills you developed, such as incident analysis, critical thinking, understanding of regulatory frameworks, and communication of sensitive information.
- How will these skills be essential in future roles involving radiation safety leadership and governance?
- Identify clear actions for continued development in the area of incident investigation and management. Are there specific guidance documents or protocols you would like to study further?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 5 |
Outcome
Investigate radiation overexposure and incidents and make recommendations for remedial actions and further reporting. |