IR(ME)R annual report 2024/25

Notifications

• There has been a small reduction in the number of notifications received this year, with 3% fewer than 2023/24 (434 compared with 447).
• Two-thirds of notifications (289) originate from within the patient pathway at either the referrer or operator points.
• Around a fifth of notifications related to equipment (76 notifications).
• Most notifications are from exposures in CT (computed tomography) (265 notifications, 61%), plain x-ray (101 notifications, 23%), and mammography (42 notifications,10%).
• We received very few notifications from within interventional or cardiology services.

Figure 5: Diagnostic imaging notifications by modality, 2024/25

Note: there were 11 notifications for Dental (including CBCT) and 15 notifications for ‘Other’ modalities, which both round to 3%.

Two-thirds of notifications originated from within the patient pathway at either the referral or the entitled operator-led practical aspects of the exposure pathway (Figure 6).

Figure 6: Origin of notifications in diagnostic imaging in 2024/25

Of all the referral notifications, 123 (92%) originated within CT. We acknowledge that this is influenced by the notification criteria for accidental exposures and the dose threshold being more relevant to CT than other lower dose modalities.

In most cases, the error occurred at the point of referral – either with the wrong patient being referred or because of a failure to cancel a referral once it had been identified as inappropriate.

Figure 7: CT: Where incidents occurred in the patient exposure pathway

In planar X-ray, the most common type of incident happened during the pre-exposure checks. This includes incorrect use of equipment, incorrect patient set up, or incorrect protocol. We have identified a specific increase in the number of incidents because of detector errors (Figure 8).

Figure 8: Where incidents occurred in the X-ray patient exposure pathway

In mammography, most errors were a result of equipment faults covering both software and hardware. We highlighted this issue and shared learning about software in last year’s report.

Inspection and enforcement activity

In 2024/25, we carried out 21 inspections in diagnostic imaging (15 in 2023/24).

We issued fewer Improvement Notices, which showed no specific theme. However, almost all inspections have resulted in at least one quality improvement recommendation to ensure compliance with the regulations. The total number of recommendations made has increased slightly, but this is largely due to carrying out more inspections.

Improvement recommendations from inspections

The following were the most common recommendations following an inspection:

Regulation 6(1) and 6(2): Recommendations under these regulations were the most common. They typically related to ensuring that there are suitable employer’s procedures in place and that relevant duty holders follow them. We continue to see employer’s procedures not being used as an effective guidance tool for operational staff, who often find them confusing.

We frequently find that the employer’s procedures did not match clinical practice and that this has not been identified locally.

Regulation 6(5): In many cases, referral guidelines were not established and accessible to referrers, as required under Regulation 6(5). As demand for imaging continues to grow, the need for robust referral guidelines has become increasingly important to support external referrers in their decision making.

Regulation 15(3): We made several recommendations against this regulation, often observing inadequate routine performance testing. This is typically for local routine performance testing within the department, where we see a lack of testing or escalation in line with local policy or expectations.

Regulation 17(4): We continue to highlight poor training records, which is often due to confused record keeping, with providers unable to provide evidence of documentation on request. We routinely see training records with one signature covering an operator’s entirety of competency set at once, rather than incremental assessment.

Key themes in diagnostic imaging

Clarifying pregnancy enquiries

During our inspections and analysis of notifications, we have identified various approaches to enquiring whether a person may be pregnant. The most common initial pregnancy queries we see for examinations in the relevant anatomical range are:

• a straightforward question of “could you be pregnant?”
• the additional use of a form that requires details of the person’s last menstrual period, with no application of the 10-day rule
• querying the date of last menstrual period with the application of the 10-day rule.

In some cases, providers decide not to differentiate between low and high-dose procedures and use one of the above approaches to cover all relevant exposures.

We have received notifications where there has been a foetal over-exposure due to the patient stating that they could not be pregnant, but without prompting them to think about their last menstrual period. We acknowledge that there are different interpretations of professional guidance, and although it is up to providers to determine their approach to implementing pregnancy enquiries, we recommend that providers consider whether their current approach for pregnancy enquiries matches the intention and is suitably robust.

We have also observed clinical practice that does not match the approach outlined in the department’s employers’ procedure. For example, this may state that relevant high-dose procedures should be scheduled within the first 10 days of the menstrual period, but with no practical application of how to manage this.

Where the employer’s procedure refers to the use of the 10-day rule, it should be clear how to apply this practically and the responsibilities for duty holders should be clearly set out. Where flow charts are used to support staff who undertake pregnancy enquiries, these should make the process clear for each situation.

Use of employer’s procedures across multiple modalities

We often come across examples of good employer’s procedures that we believe have been well thought through and incorporate the point of view of those who are required to follow them. Many procedures have helpfully become more specific and relevant to the local clinical areas.

During inspection, we often look at things from the viewpoint of a member of staff joining a new area, for example a radiographer starting to work in a cardiac catheter lab for the first time. We often identify that all operators are aware of the requirements within the procedures, such as ID or pregnancy checks, but as they move from one hospital to another within a trust – or even to a different clinical area within the same hospital – they are not as aware of any new arrangements and how to document any responses.

We encourage organisations to consider adopting this approach when updating their own employer’s procedures, promoting the idea that the procedures should support staff with specifics on ‘this is how we do it here.’

In one inspection, we noted how the trust had written different sets of employer’s procedures to reflect proper working practice within general radiography, cardiology, breast screening, and dental radiography. The service had taken the view that the arrangements in these clinical settings were sufficiently different to warrant multiple sets of procedures.

We recognise that such an approach will not work for all organisations. Others may prefer to have a set of procedures for specific modalities supported by an addendum for any nuances in specialised areas. We recognise that in some cases, due to workforce structure or rotations, it may be better to have a single set of employer’s procedures.

Co-operation between employers within incidents

The 2024 amendments to the regulations included the requirement for co-operation between IR(ME)R employers to ensure that each can comply with the requirements of the regulations. This is required when 2 or more IR(ME)R employers are involved in the exposure to a person.

In these cases, it is important to have clear lines of responsibility, escalation and communication. We have identified good working practice where employers collaborate on joint investigations and share learning widely across organisations to improve safety. This collaborative approach has resulted in identifying any actions, mitigations and training that may be required by either or both employers.

We have also seen examples of delays to notifications as responsibility was not clearly defined or because of ineffective escalation mechanisms when an issue was identified. This has also resulted in delays in identifying training requirements, procedural errors and actions required.

Effective information technology systems to reduce errors and improve patient safety.

There are many advantages of electronic systems of work, from radiology information systems (RIS) to electronic patient referrals (EPR), including workflow efficiency and improved patient care.

However, we have identified areas of increased risk that can lead to errors where information technology (IT) systems are not integrated.

Examples from notifications where non-integrated IT systems were a primary or contributory factor include:

• referrers needing to have multiple screens open to make a referral and access patient records
• difficulty in cancelling referrals
• difficulty in identifying referrers and unretrievable images.

Detector incidents

We received an increase in notifications related to repeat exposures due to the incorrect detector being selected. The vast majority were extremity exposures that were reported as a theme under the ‘M’ category. None were attributable to design features from a specific manufacturer and were from both the NHS and independent sectors. Learning from detector errors was also previously highlighted in our 2019/20 annual report.

Through our inspection programme, we have identified that some services were identifying detector errors as a theme within their governance meetings but not reporting these to us as required under the criteria.

There were several possible reasons for an additional unintended exposure:

• The patient’s own presentation being different to that in the standard protocol (for example, being unable to stand against an erect bucky). This would lead staff to use an alternative technique using a free wireless detector, often successfully for the initial projection but not for subsequent views where the system would default back to the erect bucky.
• The selectable displays of the equipment being unclear or misunderstood by operators. For example, staff believing that a green dot on the control panel suggested a specific detector was selected and enabled, when in fact it did not indicate which panel was selected.
• An unclear process when the detector battery runs flat, and whether the system automatically defaults to another detector, which can go unnoticed.
• The incorrect detector being set up in error within the protocol.

Here, we describe some of the learning identified and the actions taken to raise awareness and provide possible fixes:

Improving the equipment’s user interface

Many providers identified areas for improvement within the equipment’s user interface, which could help operators during set-up. For example:

• Some providers improved detector nomenclature and labelling
• One organisation re-arranged the order of the detector selection so that it was more logical for staff and removed detector selections that were not relevant
• Others have worked with manufacturers to add additional on-screen pop ups to remind operators to check that they have selected the correct detector

If your department has X-ray rooms from multiple manufacturers, it may help to assess differences between user interfaces and to ask operators to highlight positive attributes of certain user interfaces. This can help during discussions with manufacturers around potential changes and can help inform future procurement.

Refreshed checklists and reviewing protocols

Some providers found value in changing the tone of ‘Pause and check’ to ‘Stop and check’. This introduced a firmer approach to ensuring that staff take the time to check their set-up – even when under pressure to take the exposure quickly. Others introduced additional checks for operators, for example a specific check of whether the bucky tray was open or closed.

Departments also found it useful to review their programmed equipment protocol settings to ensure that the preset detector choices matched the expected set-up of the clinical examination. Some departments provided additional bespoke free detector protocols for use with patients who were unable to undergo an exposure with the table or vertical bucky.

Staff training and competency assessments

All operators must undergo appropriate induction training. If certain equipment is more challenging for operators, departments can consider specific periodic refresher courses. We expect organisations to implement measures to ensure staff are adequately trained to use manufacturer-specific features. Some departments used bespoke sessions in a controlled environment to provide additional support. Some organisations provided training specifically focused on the need to take their time and not rush detector selection checks – even when under time pressure.

Review actions required following an incident

All incidents should be escalated locally and subject to appropriate trend analysis, which is often discussed during governance meetings. We have received notifications where operators have not always been able to identify when an incident has occurred, resulting in multiple unintended exposures within a short space of time.

Human factors

We acknowledge that human errors will happen, and that detector errors may never be fully prevented. Detector errors have represented only a small portion of the total number of exposures in the notification received. We have seen that incidents still happen despite considering the learning available.