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Radiation Incident Investigation Report Form
Radiation Incident Investigation Report Form
INCIDENT.
1. Incident
Date of Time of Location of
Incident: Incident: incident:
Patient Patient M F MERU Incident
age: sex: definition
What speciality was patient admitted under / referred NEAR MISS? YES - NO -
from?
Incident description: (Accurately describe, in chronological order, the relevant details of what happened
leading up to, immediately before, during and after the incident and others involved):
2. Investigation
Who led the Who was on
investigation? investigation team
(include referring
clinician where
applicable)?
Was risk management involved in the investigation? Y N
Was a formal system /root cause analysis conducted? Y N
Briefly outline the methodology used by the investigation team:
Was the communication with the patient consistent with the written protocol? Y N
Who else was consulted and informed during investigation (including referrer and practitioner in charge,
other relevant staff)?
Was incident reported to regulatory bodies and Insurers (e.g., RPII, HSA, IMB, CIS, Serious Incident
Management Team for HSE), please state which:
What are the consequences/clinical impact to the patient as a result of the incident?
If ongoing medical surveillance for the patient is required, has a Y N N/A
plan been implemented?
5. Recommendations and Actions
List any immediate action that was taken to minimise harm to patient or recurrence for others:
What are the findings of the report and recommendations to prevent a similar incident occurring in future,
including follow up actions with patients, staff and others?
List additional actions that must be taken and the timeframe for completion.
Any other information relevant to this report, e.g., what is the learning for this and/or other locations?
Please return signed copy to: Private and Confidential, Medical Exposure Radiation
Unit, Oak House, Lime Tree Avenue, Millennium Park, Naas, Co. Kildare.