2. Accidental and unintended exposures

What counts

Examples: exposing the wrong patient; exposing the wrong side or region; exposing when the unit fired twice; a child present in the room; a staff member walking into the beam; using the wrong programme so dose is far above intended.

Immediate actions

1. Stop further exposures on that set if equipment may be at fault.
2. Record what happened, who was present, and estimated extra dose if your procedure requires it (RPA advice for significant events).
3. Tell the patient honestly if they received an unintended exposure (duty of candour sits alongside IR(ME)R).
4. Follow the employer’s procedure for notification — some events must be reported externally (for example to CQC in England, and in line with IR(ME)R significant accidental/unintended exposure guidance). Do not hide repeats in the day book.

Know where the incident form is before you need it.

Near misses

Wrong patient identifiers caught before exposure still need a system fix (two identifiers, not “I recognised them”).