Research Presentation Session: Physics in Medical Imaging Hot Topic with Keynote Lecture
RPS 1213 - Hot Topic: error reporting
March 6, 08:00 - 09:00 CET
10 min
Keynote Lecture
Donald P. Frush, Durham / United States
6 min
Radiation safety deviation reporting of X-ray practices in Finland: analysis of the last 10 years
Tommi Hietamies, Vantaa / Finland
Author Block: E. Hallinen, T. Hietamies, I. P. Kuurne, A. Lajunen, V. Ruonala, J. Suutari, P. Tenkanen-Rautakoski; Vantaa/FI
Purpose: This study aims to describe the characteristics, frequency, and outcomes of reported radiation safety deviations in healthcare X-ray practices in Finland, and to highlight their role in supporting continuous safety improvement.
Methods or Background: In Finland, radiation safety deviations in healthcare X-ray practices must be reported to the Radiation and Nuclear Safety Authority (STUK). Deviations are classified into significant cases, which must be reported immediately, and less significant cases, which are submitted annually. Since 2015, approximately 270 significant and 12,650 less significant deviations have been reported. The reporting system is regarded as an indicator of a strong safety culture.
Deviation reports submitted to STUK between 2015 and 2024 were analyzed. Reports were classified into predefined categories. Descriptive analyses included frequency distributions, trends over time, and typical causes. From 2025 onwards, reporting requirements will also include preventive measures taken for each deviation type.
Results or Findings: No severe radiation safety incidents have been reported since the implementation of systematic reporting. Patient exposures resulting from deviations remained below 100 mSv, occupational exposures below 1 mSv, and unintended foetal exposures below 40 mGy. The most common deviation was failed examinations due to incident, requiring repetition, typically caused by technical problems or human error. Analysis of reports and anonymized case studies have been used as educational tools in radiation safety training.
Conclusion: The systematic reporting of radiation safety deviations has proven effective in monitoring and improving safety culture in Finnish healthcare X-ray practices. The introduction of preventive action reporting from 2025 is expected to further strengthen proactive safety management.
Limitations: Not all radiation safety deviations are reported to STUK.
Funding for this study: This study is a by-product of statutory regulatory oversight, conducted and funded by STUK.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: This study aims to describe the characteristics, frequency, and outcomes of reported radiation safety deviations in healthcare X-ray practices in Finland, and to highlight their role in supporting continuous safety improvement.
Methods or Background: In Finland, radiation safety deviations in healthcare X-ray practices must be reported to the Radiation and Nuclear Safety Authority (STUK). Deviations are classified into significant cases, which must be reported immediately, and less significant cases, which are submitted annually. Since 2015, approximately 270 significant and 12,650 less significant deviations have been reported. The reporting system is regarded as an indicator of a strong safety culture.
Deviation reports submitted to STUK between 2015 and 2024 were analyzed. Reports were classified into predefined categories. Descriptive analyses included frequency distributions, trends over time, and typical causes. From 2025 onwards, reporting requirements will also include preventive measures taken for each deviation type.
Results or Findings: No severe radiation safety incidents have been reported since the implementation of systematic reporting. Patient exposures resulting from deviations remained below 100 mSv, occupational exposures below 1 mSv, and unintended foetal exposures below 40 mGy. The most common deviation was failed examinations due to incident, requiring repetition, typically caused by technical problems or human error. Analysis of reports and anonymized case studies have been used as educational tools in radiation safety training.
Conclusion: The systematic reporting of radiation safety deviations has proven effective in monitoring and improving safety culture in Finnish healthcare X-ray practices. The introduction of preventive action reporting from 2025 is expected to further strengthen proactive safety management.
Limitations: Not all radiation safety deviations are reported to STUK.
Funding for this study: This study is a by-product of statutory regulatory oversight, conducted and funded by STUK.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Patterns and Safety Implications of Unintended Patient Exposures in Imaging and Radiotherapy Across Multiple Countries
Chrysa Paraskevopoulou, Athens / Greece
Author Block: C. Paraskevopoulou1, A. Papachristodoulou1, C. D. Filho2, D. Baltazar3, C. Colmo4, A. Roncacci1; 1Hague/NL, 2Barcelona/ES, 3Amadora/PT, 4Padua/IT
Purpose: Unintended patient exposures in ionizing radiation procedures, including diagnostic imaging (CT, X-ray, PET-CT, Mammography, SPECT-CT) and therapeutic applications (Radiotherapy, Brachytherapy), pose risks to safety, diagnostic accuracy, and treatment precision. This study analyzed unintended exposure incidents across multiple countries to identify patterns, underlying causes, and opportunities for safety improvement.
Methods or Background: Incident data from a centralized multi-national reporting system were analyzed over a three-year period. Incidents were categorized as repeated examination, wrong patient, wrong examination, wrong site, and wrong side. Severity was classified as no physical harm, minor, medium, serious, or severe. Rates were calculated relative to 8.18 million ionizing radiation procedures performed in 376 centers across 15 countries.
Results or Findings: Across 8.18 million ionizing radiation procedures, 369 unintended patient exposures were identified (0.0011%). Repeated examinations and wrong examination events together accounted for over half of all incidents, reflecting common issues such as motion artifacts, technical failures, or request-to-procedure mismatches. Wrong patient exposures were also frequent, representing nearly one quarter of cases, while wrong site and wrong side events were less common but clinically significant (Fig.1). Most events were minor or medium in severity, yet a consistent presence of serious cases underscores the importance of systematic monitoring and targeted preventive measures.
Conclusion: Although unintended patient exposures represent a very small fraction of ionizing radiation procedures, their implications for safety and quality of care are significant. The high share of repeated and wrong examination events highlights the need for workflow optimization, request-to-procedure verification, improved patient communication, and enhanced personel training. Preventive strategies should also address wrong patient, wrong site, and wrong side incidents. Continuous monitoring are essential to guide systematic improvements and targeted preventive measures, supporting a stronger safety culture across imaging and radiotherapy services.
Limitations: N/A
Funding for this study: N/A
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: Unintended patient exposures in ionizing radiation procedures, including diagnostic imaging (CT, X-ray, PET-CT, Mammography, SPECT-CT) and therapeutic applications (Radiotherapy, Brachytherapy), pose risks to safety, diagnostic accuracy, and treatment precision. This study analyzed unintended exposure incidents across multiple countries to identify patterns, underlying causes, and opportunities for safety improvement.
Methods or Background: Incident data from a centralized multi-national reporting system were analyzed over a three-year period. Incidents were categorized as repeated examination, wrong patient, wrong examination, wrong site, and wrong side. Severity was classified as no physical harm, minor, medium, serious, or severe. Rates were calculated relative to 8.18 million ionizing radiation procedures performed in 376 centers across 15 countries.
Results or Findings: Across 8.18 million ionizing radiation procedures, 369 unintended patient exposures were identified (0.0011%). Repeated examinations and wrong examination events together accounted for over half of all incidents, reflecting common issues such as motion artifacts, technical failures, or request-to-procedure mismatches. Wrong patient exposures were also frequent, representing nearly one quarter of cases, while wrong site and wrong side events were less common but clinically significant (Fig.1). Most events were minor or medium in severity, yet a consistent presence of serious cases underscores the importance of systematic monitoring and targeted preventive measures.
Conclusion: Although unintended patient exposures represent a very small fraction of ionizing radiation procedures, their implications for safety and quality of care are significant. The high share of repeated and wrong examination events highlights the need for workflow optimization, request-to-procedure verification, improved patient communication, and enhanced personel training. Preventive strategies should also address wrong patient, wrong site, and wrong side incidents. Continuous monitoring are essential to guide systematic improvements and targeted preventive measures, supporting a stronger safety culture across imaging and radiotherapy services.
Limitations: N/A
Funding for this study: N/A
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Projected Impact of The U.S. Quality Measure, Excessive Radiation Dose or Inadequate Image Quality for Diagnostic CT on Radiation Dose and Projected Cancer Risks
Rebecca Smith-Bindman, San Francisco / United States
Author Block: R. Smith-Bindman1, G. Frija2; 1San Francisco, CA/US, 2Paris/FR
Purpose: Excessive radiation doses in CT exams are a patient safety concern. Provider-based financial incentives in the U.S.have successfully improved patient safety. UCSF, with funding from the Centers for Medicare & Medicaid Services, developed a quality measure for CT to reduce unnecessary radiation doses while maintaining diagnostic value. During the presentation, speakers will detail the measure’s methodology, discuss its impact on projected cancers, and explore its potential application in Europe.
Methods or Background: The measure automates CT radiation/image noise calculations using standardized data based on scan indications. Eligible adult CT exams are assigned to categories with thresholds for allowable radiation doses and noise based on ICD-10-CM and CPT codes. Radiation dose is adjusted for patient size, and exams are flagged as “out-of-range” if they exceed thresholds supported by radiologists’ estimates of diagnostic value. Testing across 7 health systems, 16 hospitals, and 606 clinicians included 48,500 CT exams, with 33% flagged as out-of-range. Data from an international CT registry showed approximately 28% of European exams were out-of-range.
Results or Findings: If dose thresholds had been applied to the 90 million CT exams conducted among 59 million adults in the U.S. in 2023, the projected number of future cancers would decrease from 93,000 to 69,000—a 26% reduction. Abdomen and pelvis CT contributed the highest cancer burden, with 31,200 projected cancers, which could be reduced by 9,556 if thresholds were implemented. Chest CT followed, with 21,500 projected cancers, 8,376 of which could be prevented. These two CT categories represent key targets for optimizing and standardizing radiation dose protocols.
Conclusion: The measure is being adopted across U.S. hospital and physician payment programs, with over 3,500 hospitals working towards reporting. Financial incentives will drive improvements in patient safety and care quality.
Limitations: None
Funding for this study: The quality measure was funded by the U.S. Centers for Medicare and Medicaid Services, and the Patient Centered Outcomes Research Institute
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: Excessive radiation doses in CT exams are a patient safety concern. Provider-based financial incentives in the U.S.have successfully improved patient safety. UCSF, with funding from the Centers for Medicare & Medicaid Services, developed a quality measure for CT to reduce unnecessary radiation doses while maintaining diagnostic value. During the presentation, speakers will detail the measure’s methodology, discuss its impact on projected cancers, and explore its potential application in Europe.
Methods or Background: The measure automates CT radiation/image noise calculations using standardized data based on scan indications. Eligible adult CT exams are assigned to categories with thresholds for allowable radiation doses and noise based on ICD-10-CM and CPT codes. Radiation dose is adjusted for patient size, and exams are flagged as “out-of-range” if they exceed thresholds supported by radiologists’ estimates of diagnostic value. Testing across 7 health systems, 16 hospitals, and 606 clinicians included 48,500 CT exams, with 33% flagged as out-of-range. Data from an international CT registry showed approximately 28% of European exams were out-of-range.
Results or Findings: If dose thresholds had been applied to the 90 million CT exams conducted among 59 million adults in the U.S. in 2023, the projected number of future cancers would decrease from 93,000 to 69,000—a 26% reduction. Abdomen and pelvis CT contributed the highest cancer burden, with 31,200 projected cancers, which could be reduced by 9,556 if thresholds were implemented. Chest CT followed, with 21,500 projected cancers, 8,376 of which could be prevented. These two CT categories represent key targets for optimizing and standardizing radiation dose protocols.
Conclusion: The measure is being adopted across U.S. hospital and physician payment programs, with over 3,500 hospitals working towards reporting. Financial incentives will drive improvements in patient safety and care quality.
Limitations: None
Funding for this study: The quality measure was funded by the U.S. Centers for Medicare and Medicaid Services, and the Patient Centered Outcomes Research Institute
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Organ-specific radiation doses after mispositioning or scan direction variation: Impact of single versus dual scanogram across four different CT-scanners
Louise D'Hondt, Ghent / Belgium
Author Block: L. D'Hondt1, C. Haentjens2, A. Snoeckx3, K. Bacher1; 1Ghent/BE, 2Leuven/BE, 3Antwerp/BE
Purpose: With the considerable number of low-dose CT examinations for lung cancer screening, participant mispositioning or scan direction variations are expected. These variations affect automatic tube current modulation (ATCM), but dose implications across CT-models remain unknown. Moreover, current screening guidelines lack scanogram specifications. This study simulated organ-specific doses when protocol deviations were preceded by either single or dual scanogram.
Methods or Background: ATCM-profiles were established using the Alderson Rando phantom on four CT-scanners (GE Revolution, Siemens SOMATOM Definition Flash, Canon Aquilion ONE, Philips Spectral CT 7500). Protocol variations included vertical and lateral mispositioning (2cm increments) and scan direction changes (craniocaudal, caudocranial), each preceded by either a single posteroanterior (PA) or dual (PA+Lateral) scanogram. Each variation was simulated with the ImpactMc Monte Carlo software for 32 patient-specific voxelmodels and organ doses were calculated (lungs, heart, thyroid, liver, breasts).
Results or Findings: GE and Siemens scanners showed considerable linear increase in organ doses (respectively 18-50% and 5-25%) with vertical/downward mispositioning using a single PA scanogram. This was eliminated by adding a lateral scanogram. Canon and Philips scanners generally displayed stable ATCM-profiles and dose levels after vertical mispositioning, regardless of scanogram type.
Solely the Canon scanner showed substantial average dose increases of 37.5% and 34% after respectively a single and dual scanogram across lateral mispositioning.
The ATCM-behaviour upon changing to the craniocaudal scan direction is highly model dependent. However, combined with the dual scanogram, dose deviations are minimised for all scanners except for Siemens, where no differences are seen.
Conclusion: An additional lateral scanogram can mitigate considerable organ dose increases related to scan protocol deviations. Since ATCM-behaviour varies across CT-scanner models, scanner-specific evaluation and optimisation should involve medical physics expertise.
Limitations: The limitations of the study are the use of a phantom.
Funding for this study: Funding was provided by the FWO “Kom op tegen Kanker”-project for lung cancer screening research in Belgium. (Project number: G0B1922N).
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: With the considerable number of low-dose CT examinations for lung cancer screening, participant mispositioning or scan direction variations are expected. These variations affect automatic tube current modulation (ATCM), but dose implications across CT-models remain unknown. Moreover, current screening guidelines lack scanogram specifications. This study simulated organ-specific doses when protocol deviations were preceded by either single or dual scanogram.
Methods or Background: ATCM-profiles were established using the Alderson Rando phantom on four CT-scanners (GE Revolution, Siemens SOMATOM Definition Flash, Canon Aquilion ONE, Philips Spectral CT 7500). Protocol variations included vertical and lateral mispositioning (2cm increments) and scan direction changes (craniocaudal, caudocranial), each preceded by either a single posteroanterior (PA) or dual (PA+Lateral) scanogram. Each variation was simulated with the ImpactMc Monte Carlo software for 32 patient-specific voxelmodels and organ doses were calculated (lungs, heart, thyroid, liver, breasts).
Results or Findings: GE and Siemens scanners showed considerable linear increase in organ doses (respectively 18-50% and 5-25%) with vertical/downward mispositioning using a single PA scanogram. This was eliminated by adding a lateral scanogram. Canon and Philips scanners generally displayed stable ATCM-profiles and dose levels after vertical mispositioning, regardless of scanogram type.
Solely the Canon scanner showed substantial average dose increases of 37.5% and 34% after respectively a single and dual scanogram across lateral mispositioning.
The ATCM-behaviour upon changing to the craniocaudal scan direction is highly model dependent. However, combined with the dual scanogram, dose deviations are minimised for all scanners except for Siemens, where no differences are seen.
Conclusion: An additional lateral scanogram can mitigate considerable organ dose increases related to scan protocol deviations. Since ATCM-behaviour varies across CT-scanner models, scanner-specific evaluation and optimisation should involve medical physics expertise.
Limitations: The limitations of the study are the use of a phantom.
Funding for this study: Funding was provided by the FWO “Kom op tegen Kanker”-project for lung cancer screening research in Belgium. (Project number: G0B1922N).
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Harmonizing Dose Monitoring and QA Reporting in Dental Cone-beam Computed Tomography
Satu Inkinen, Helsinki / Finland
Author Block: S. Inkinen, J. H. J. Ketola, A-M. Vitikainen, M. Kortesniemi; Helsinki/FI
Purpose: We report a case emphasizing the need for harmonized external quality assurance (QA) in dental imaging, specifically regarding dose area product (DAP) monitoring. Our existing QA procedure was modified with an electronic form that radiographers complete during device QA. This form also includes externally verified DAP monitoring values, since, our dose monitoring platform cannot currently track DAP for dental cone-beam computed tomography (CBCT) units.
Methods or Background: Dental CBCT devices follow manufacturer-specific QA protocols using custom phantoms. These protocols often omit DAP monitoring, and dose monitoring systems may not receive input from dental devices via Radiation Dose Structured Reports, or only report CTDI instead of DAP that is the dose unit used for diagnostic reference levels in Finland.
QA is required at least twice a year or following service. We had a case that after a service, a dental unit’s software was reverted to factory settings (exposure settings altered) via service engineer without notifying users, leading to consistently elevated patient doses. This went unnoticed due to the lack of DAP data integration to our dose monitoring systems.
Results or Findings: We developed a multi-modality QA system using open-source libraries and a web-based interface at HUS Diagnostic Center. The system now includes dental device QA via electronic forms and monthly DAP value checks for the most common protocol (teeth). The updated system streamlines QA, eliminates parallel spreadsheet logging, and improves data consistency. It also addresses the previously reported adverse event by incorporating DAP monitoring.
Conclusion: The revised QA process is scalable across dental imaging units. The web-based form harmonizes documentation and enables dose monitoring, supporting safer and more transparent imaging practices. Manufacturers should ensure DAP values are included in baseline system checks.
Limitations: No limitations were identified.
Funding for this study: None.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: We report a case emphasizing the need for harmonized external quality assurance (QA) in dental imaging, specifically regarding dose area product (DAP) monitoring. Our existing QA procedure was modified with an electronic form that radiographers complete during device QA. This form also includes externally verified DAP monitoring values, since, our dose monitoring platform cannot currently track DAP for dental cone-beam computed tomography (CBCT) units.
Methods or Background: Dental CBCT devices follow manufacturer-specific QA protocols using custom phantoms. These protocols often omit DAP monitoring, and dose monitoring systems may not receive input from dental devices via Radiation Dose Structured Reports, or only report CTDI instead of DAP that is the dose unit used for diagnostic reference levels in Finland.
QA is required at least twice a year or following service. We had a case that after a service, a dental unit’s software was reverted to factory settings (exposure settings altered) via service engineer without notifying users, leading to consistently elevated patient doses. This went unnoticed due to the lack of DAP data integration to our dose monitoring systems.
Results or Findings: We developed a multi-modality QA system using open-source libraries and a web-based interface at HUS Diagnostic Center. The system now includes dental device QA via electronic forms and monthly DAP value checks for the most common protocol (teeth). The updated system streamlines QA, eliminates parallel spreadsheet logging, and improves data consistency. It also addresses the previously reported adverse event by incorporating DAP monitoring.
Conclusion: The revised QA process is scalable across dental imaging units. The web-based form harmonizes documentation and enables dose monitoring, supporting safer and more transparent imaging practices. Manufacturers should ensure DAP values are included in baseline system checks.
Limitations: No limitations were identified.
Funding for this study: None.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Errors in hybrid nuclear medicine: overview, challenges, and prevention
Kirill Skovorodko, Vilnius / Lithuania
Author Block: K. Skovorodko, D. Serėnaitė-Pečiulė, V. Statkus, R. Komiagienė, L. Krynke, B. Gricienė; Vilnius/LT
Purpose: Hybrid nuclear medicine methods such as PET/CT, SPECT/CT and PET/MRI have significantly improved diagnostic accuracy by combining functional and anatomical data. Despite the clinical benefits of these methods, the complexity nuclear medicine procedures and these modalities entails a wide range of potential errors, ranging from technical to human factors. The aim of this study was to analyse the reported errors in Lithuanian hospitals providing nuclear medicine services, identify the main problems associated with these errors and discuss possible ways to prevent them.
Methods or Background: An assessment of official error (unintended events and accidents) registration data for the period 2020–2025 in Lithuanian hospitals providing nuclear medicine services was conducted. An oral survey of nuclear medicine department personnel was also conducted to assess potential weaknesses that could lead to errors and identify possible measures to prevent them.
Results or Findings: Prevention strategies target both to quality assurance system and human performance should be implemented. Key measures include compressive quality assurance of the equipment, standardized training and practice, and structured reporting to reduce errors. AI and advanced software can automate checks, limit misregistration, and support interpretation. A safety-focused culture with error reporting and regular clinical audits ensures early detection and ongoing improvement.
Conclusion: In conclusion, errors in hybrid nuclear medicine are due to many factors, reflecting both technological complexity and human limitations. Some of the potential errors could be minimized by using artificial intelligence solutions in nuclear medicine. By addressing these challenges through training, protocol standardization, and technological innovation, the field can improve diagnostic reliability while ensuring patient safety and optimal clinical outcomes. Errors in hybrid nuclear medicine not only compromise diagnostic reliability but can also lead to inappropriate clinical decisions and increased radiation exposure.
Limitations: Not applicable
Funding for this study: No funding was provided for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: Hybrid nuclear medicine methods such as PET/CT, SPECT/CT and PET/MRI have significantly improved diagnostic accuracy by combining functional and anatomical data. Despite the clinical benefits of these methods, the complexity nuclear medicine procedures and these modalities entails a wide range of potential errors, ranging from technical to human factors. The aim of this study was to analyse the reported errors in Lithuanian hospitals providing nuclear medicine services, identify the main problems associated with these errors and discuss possible ways to prevent them.
Methods or Background: An assessment of official error (unintended events and accidents) registration data for the period 2020–2025 in Lithuanian hospitals providing nuclear medicine services was conducted. An oral survey of nuclear medicine department personnel was also conducted to assess potential weaknesses that could lead to errors and identify possible measures to prevent them.
Results or Findings: Prevention strategies target both to quality assurance system and human performance should be implemented. Key measures include compressive quality assurance of the equipment, standardized training and practice, and structured reporting to reduce errors. AI and advanced software can automate checks, limit misregistration, and support interpretation. A safety-focused culture with error reporting and regular clinical audits ensures early detection and ongoing improvement.
Conclusion: In conclusion, errors in hybrid nuclear medicine are due to many factors, reflecting both technological complexity and human limitations. Some of the potential errors could be minimized by using artificial intelligence solutions in nuclear medicine. By addressing these challenges through training, protocol standardization, and technological innovation, the field can improve diagnostic reliability while ensuring patient safety and optimal clinical outcomes. Errors in hybrid nuclear medicine not only compromise diagnostic reliability but can also lead to inappropriate clinical decisions and increased radiation exposure.
Limitations: Not applicable
Funding for this study: No funding was provided for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Replacing Error-Prone Spreadsheets with a Free and Open-Source QC Management System: A QATrack+ Pilot Study Using the Pylinac ACR MRI Large Phantom Module
Clarissa Attard, Birkirkara / Malta
Author Block: C. Attard, D. J. M. Scicluna, K. Schembri, N. Vella, E. Pace, C. J. Caruana; Msida/MT
Purpose: Medical Physics Quality Control (MPQC) often relies on improvised, locally-developed, spreadsheet-based, software tools used to manually collect, analyse, and present results. This may lead to undetected inconsistencies and, data-entry and formula errors. A more reproducible and controlled QC process is essential. This work reviewed spreadsheet-based error in current practice and explored QATrack+ as an alternative robust centrally managed solution.
Methods or Background: A literature review was conducted using Google Scholar with the search string “error AND spreadsheet AND medical-physics” (2015–present), which retrieved n = 1,780 papers. QATrack+, a free-open-source-software (FOSS) based alternative to spreadsheets was pilot-tested on annual MRI MPQC based on ACR guidelines.
Results or Findings: No previous studies were identified that investigated, classified or quantified errors emerging from the use of spreadsheet software in MPQC, despite hundreds of ‘horror-stories’ documented by the European Spreadsheet Risks Interest Group. The fact that studies have shown that the vast majority of MPQC rely on spreadsheets which are not compliant with the Flexible, Appropriate, Structured, Transparent (FAST) Standard for spreadsheet document control, indicates that errors are likely to be present which are undetected. QATrack+ supports the following main data-integration routes: external analysis with manual or automated API data entry and internal analysis with either non-version-controlled or version-controlled custom Python code. The latter preferred method was used in this study.
Conclusion: A centrally managed, controlled system such as QATrack+ is essential particularly considering that software is legally a medical device under EU regulations. The QATrack+ based MRI pilot programme developed demonstrates that such tools are within reach of all medical physics departments.
Limitations: N/A
Funding for this study: N/A
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: Medical Physics Quality Control (MPQC) often relies on improvised, locally-developed, spreadsheet-based, software tools used to manually collect, analyse, and present results. This may lead to undetected inconsistencies and, data-entry and formula errors. A more reproducible and controlled QC process is essential. This work reviewed spreadsheet-based error in current practice and explored QATrack+ as an alternative robust centrally managed solution.
Methods or Background: A literature review was conducted using Google Scholar with the search string “error AND spreadsheet AND medical-physics” (2015–present), which retrieved n = 1,780 papers. QATrack+, a free-open-source-software (FOSS) based alternative to spreadsheets was pilot-tested on annual MRI MPQC based on ACR guidelines.
Results or Findings: No previous studies were identified that investigated, classified or quantified errors emerging from the use of spreadsheet software in MPQC, despite hundreds of ‘horror-stories’ documented by the European Spreadsheet Risks Interest Group. The fact that studies have shown that the vast majority of MPQC rely on spreadsheets which are not compliant with the Flexible, Appropriate, Structured, Transparent (FAST) Standard for spreadsheet document control, indicates that errors are likely to be present which are undetected. QATrack+ supports the following main data-integration routes: external analysis with manual or automated API data entry and internal analysis with either non-version-controlled or version-controlled custom Python code. The latter preferred method was used in this study.
Conclusion: A centrally managed, controlled system such as QATrack+ is essential particularly considering that software is legally a medical device under EU regulations. The QATrack+ based MRI pilot programme developed demonstrates that such tools are within reach of all medical physics departments.
Limitations: N/A
Funding for this study: N/A
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
6 min
Reporting of MRI Incidents and Near-misses at a Multi-site Imaging Centre
Laura-Elina Lahtela, Helsinki / Finland
Author Block: L-E. Lahtela, T. Mäkelä, T. Kaasalainen, M. Timonen; Helsinki/FI
Purpose: MRI safety relies on comprehensive staff training, well-defined duties, thorough risk awareness, access control, strict screening protocols, emergency preparedness, and management of safety incidents and concerns. Fostering an ongoing safety culture is one of the most influential strategies for sustaining and enhancing safety practices. Operating within a multi-site and multi-departmental environment introduces additional factors that must be addressed to ensure effective communication and coordination. Over the years, we have improved our incident reporting and handling protocols.
Methods or Background: Historically, MRI safety practices in Finland have largely been determined by individual imaging facilities and local established protocols. This is in contrast with ionising radiation modalities, where nationwide regulation has long promoted best clinical practices, safety monitoring, and communication.
Results or Findings: We created an online tool to report MRI incidents and near misses. Typical reported incidents include small metal objects in the scanning room and uncertainty regarding the safety of undisclosed implants or other foreign bodies. We have also identified the lack of MRI safety training of visiting non-MRI personnel as a recurring and significant risk factor. The main benefit of the tool has been lowering the barrier to report incidents. All findings are communicated in regular meetings and incorporated into staff training sessions. Significant accidents reported by other institutions worldwide are also reviewed and discussed.
Conclusion: If the safety culture does not encourage constructive feedback and open discussion, there is a risk of underreporting and an increased likelihood of preventable accidents. MRI safety can be enhanced by promoting the reporting, management, and documentation of all incidents, near-misses, and potential safety issues. The reporting system should be simple and user-friendly to encourage participation and effectiveness, and push towards continuous improvement of MRI safety.
Limitations: No limitations were identified.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information:
Purpose: MRI safety relies on comprehensive staff training, well-defined duties, thorough risk awareness, access control, strict screening protocols, emergency preparedness, and management of safety incidents and concerns. Fostering an ongoing safety culture is one of the most influential strategies for sustaining and enhancing safety practices. Operating within a multi-site and multi-departmental environment introduces additional factors that must be addressed to ensure effective communication and coordination. Over the years, we have improved our incident reporting and handling protocols.
Methods or Background: Historically, MRI safety practices in Finland have largely been determined by individual imaging facilities and local established protocols. This is in contrast with ionising radiation modalities, where nationwide regulation has long promoted best clinical practices, safety monitoring, and communication.
Results or Findings: We created an online tool to report MRI incidents and near misses. Typical reported incidents include small metal objects in the scanning room and uncertainty regarding the safety of undisclosed implants or other foreign bodies. We have also identified the lack of MRI safety training of visiting non-MRI personnel as a recurring and significant risk factor. The main benefit of the tool has been lowering the barrier to report incidents. All findings are communicated in regular meetings and incorporated into staff training sessions. Significant accidents reported by other institutions worldwide are also reviewed and discussed.
Conclusion: If the safety culture does not encourage constructive feedback and open discussion, there is a risk of underreporting and an increased likelihood of preventable accidents. MRI safety can be enhanced by promoting the reporting, management, and documentation of all incidents, near-misses, and potential safety issues. The reporting system should be simple and user-friendly to encourage participation and effectiveness, and push towards continuous improvement of MRI safety.
Limitations: No limitations were identified.
Funding for this study: No funding was received for this study.
Has your study been approved by an ethics committee? Not applicable
Ethics committee - additional information: