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Published on: January 22, 2018
Evaluation of exposure incidents in PET-CT examinations through root cause analysis
Angélica Valentina Osorio Oliveros1, Johana Alexandra Velasco Jaramillo2, Harley Alejo-Martínez2
1Departamento de Física, Universidad del Valle, Cali, Colombia.
Purpose:
To implement a continuous improvement cycle aimed at identifying and reducing radiation exposure incidents in patients undergoing PET-CT scans.
Methods:
A comparative quasi-experimental study was conducted within a nuclear medicine department, analyzing two separate periods: October-December 2022 (n = 604 patients) "before" group and July-September 2023 (n = 758 patients) "after" group.
Results:
We observed 21 radiation exposure incidents in adult patients in the "before" group. These incidents were primarily caused by errors in setting the Bedside Education Display (BED) time, incorrect patient positioning, and selecting inappropriate protocols. As a corrective step, we provided training to technical staff focusing on proper patient centering and BED time setup. In the "after" group, following this intervention, we recorded 15 incidents in adult patients, evidencing a decrease in total incidents. Notably, there were no cases related to the overall Dose Length Product (DLP). Fisher's exact test analysis confirmed a statistically significant reduction in incidents for two dose indicators after the intervention.
Conclusion:
We emphasize the critical importance of ongoing monitoring and analysis to identify and minimize incidents related to unnecessary radiation exposure. Despite optimized protocols, process failures can still lead to avoidable exposures.
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