Notifications from nuclear medicine

  • 63 notifications received (35 notifications in 2020/21)
  • represents 10% of all notifications received
  • 68% of notifications were from NHS acute trusts
  • 38% of notifications were from PET-CT and PET-MR .

There has been a marked increase in the number of nuclear medicine notifications since 2020/21. This has been across all 4 sub-modalities and cannot be attributed to any one field. 

These figures do not include any notifications relating to licensing breaches, where a SAUE did not occur. We manage these voluntary notifications through a separate process and webform. 

Figure 4: Notifications from nuclear medicine by sub-modality, 1 April 2021 to 31 March 2022

Sub-modality Number of notifications Percentage of notifications
PET-CT or PET-MR 24 38%
Diagnostic imaging 22 35%
Radionuclide therapy 13 21%
In vitro study 4 6%
Total 63 100%

Source: CQC SAUE notifications 2021/22

Types of error

Operator errors are still the major source of notifications. Mistakes in the preparation or administration of radiopharmaceuticals was the most common of these (figure 5).

We also continue to see a large number of notifications relating to the performance of equipment. In 2021/22, we received 3 notifications of equipment issues caused by failure of ancillary systems, in contrast to the previous year when there were none. These tended to relate to failure of chillers and cooling systems in imaging suites, which caused the scanner to stall.

Figure 5 Notifications from nuclear medicine by detailed error type, 1 April 2021 to 31 March 2022

 

Tier 1: Operator (24 notifications)

Tier 2: Pharmaceutical or contrast (13 notifications)

Tier 3:

  • Preparation (8 notifications)
  • Administration (5 notifications)

Tier 2: Pre-exposure checks (6 notifications)

Tier 3:

  • Wrong use of equipment (5 notifications)
  • Wrong patient, position, set-up or protocol (1 notification)

Tier 2: Authorisation (2 notifications)

Tier 3:

  • Incorrect authorisation (2 notifications)

Tier 2: Clinical history (1 notification)

Tier 3:

  • Failure to check history or details (1 notification)

Tier 2: Patient checks (1 notification)

Tier 3:

  • Patient ID error (1 notification)

Tier 2: Post examination (1 notification)

Tier 3:

  • Failure to upload images (1 notification)

 

Tier 1: Referrer (13 notifications)

Tier 2: Incorrect referral (9 notifications)

Tier 3:

  • Wrong patient (7 notifications)
  • Wrong anatomy (1 notification)
  • Wrong modality (1 notification)

Tier 2: Incorrect information (4 notifications)

Tier 3:

  • Failure to cancel (4 notifications)

 

Tier 1: Equipment (11 notifications)

Tier 2: Equipment related (11 notifications)

Tier 3:

  • Hardware (7 notifications)
  • Ancillary failure (3 notifications)
  • Software (1 notifications)

 

Tier 1: Practitioner (1 notification)

Tier 2: Safety checks (1 notification)

Tier 3:

  • Patient ID error (1 notification)

 

Tier 1: Other (14 notifications)

Administrative staff error (4 notifications)

Tier 3:

  • Other admin error (3 notifications)
  • RIS input error (1 notification)

Tier 2: Patient related (4 notifications)

Tier 3:

  • Patient issue (3 notifications)
  • Unknown pregnancy (1 notification)

Tier 2: Other (4 notifications)

Tier 3:

  • Not listed above (4 notifications)

Tier 2: Made in error or withdrawn (2 notifications)

Tier 3:

  • Below threshold (2 notifications)

Total: 63 notifications

Source: CQC SAUE notifications, 2021/22

Licensing notifications

Employers can notify us voluntarily about licensing breaches using a separate webform outside of the process for statutory notification of SAUEs. We have received only a small number of notifications in this area, but key themes included:

  • practitioners failing to renew their licence, which the employer did not detect
  • research studies going ahead before the employer’s licence was in place
  • certain procedures accidentally omitted from the application form when applying for a new or renewed licence.

We investigate each licensing breach to look for any trends that we can highlight to help employers. Any further action we may take depends on the risk involved.