Table 2 Study characteristic for included incident report reviews and case studies (n = 11)

Nihonyanagi et al., 2006* [20]

To report on multidrug-resistant Pseudomonas Aeruginosa isolated from clinical specimens in two patients

Portable X-ray device in internal medicine ward (Japan)

2 patients with multidrug-resistant Pseudomonas Aeruginosa

• Suspected that an individual radiographer neglected handwashing at the time of each patient’s X-ray procedure

Panella et al., 2008 [21]

To describe several cases of nosocomial HCV transmission

2 public hospitals, 1 private diagnostic centre. (Spain)

6 cases of HCV

• Possible source of transmission was a CT scan with contrast, health personnel manipulated the extension tube by disconnecting the tube from the patient first, and then from the equipment without changing gloves

• No risk of blood contamination was detected from a contrast injector with automatic load from a 500-mL bottle that was shared by > 4 persons

Moore et al., 2011 [22]

To identify the source of incident HCV infection in a patient without identified risk factors, who had undergone myocardial perfusion imaging 6 weeks prior to diagnosis

Outpatient cardiology clinic. (USA)

2 potential source patients and 5 newly infected patients

• Evidence of HCV transmission among patients who had undergone myocardial perfusion imaging at the cardiology clinical on 2 separate dates

• Transmission of HCV due to unsafe injection practices during myocardial perfusion imaging

• Possibility that multi-patient use of vials occurred

Chitnis et al., 2012 [23]

To investigate an outbreak of bacterial meningitis at an outpatient radiology clinic, determine the source and implement measures to prevent additional infections

Radiology clinic (USA)

35 cases of bacterial meningitis

• Health care professional did not wear face mask; lapses in injection practice

• Targeted education is needed among radiology health care professionals

Kim et al., 2013 [24]

To report on investigation and recommendations to control joint infections following arthrograms

MRI, outpatient radiology centre (USA)

7 cases (5 confirmed, 2 probable) identified, underwent procedure during a 1-week period

• No written procedures or documentation for infection control, aseptic-technique practices, medication preparation area cleaning/disinfection, staff training, or competency evaluations

• Post-incident investigation observed that radiographers did not wash hands before preparation of injectable solutions; wore visibly soiled white coats, breaks in aseptic technique during preparation

• Each vial of contrast media (labelled as ‘single dose’ by manufacturer), was re-entered with new syringes or needles multiple times for use on multiple patients

Mansouri et al., 2015 [25]

To describe multiyear experience in incident reporting related to MRI in large academic medical centre

MRI, large academic medical centre. (USA)

Infection control accounted for 0.4% of reported incidents

• Examples of incidents: patient was on tuberculosis precautions and staff member interacting with patient was not informed; needle stick injury while disposing needle; respiratory therapist detached ventilator tubing from patient on precautions for Methicillin-resistant Staphylococcus aureus, and handed it to staff member, saliva and fluid splashed in staff member’s face

Shteyer et al., 2019 [26]

To describe an outbreak of AHC in 12 patients

CT with contrast media. (Israel)

12 patients who received intravenous saline flush from a single multi-dose vial after intravenous contrast administration for a CT scan

• Probability of intravenous saline flush event resulting in transmission of Hepatitis C

• Modelling suggested that microliter volumes of contaminated blood caused an outbreak of AHC during CT

• Evaluation of the CT protocol and practices of the CT technicians identified the saline flush as the common source of exposure among the AHC patients

Zakrzewska et al., 2019* [27]

To analyse epidemiological situation of HCV in Poland in 2017

CT with contrast, hospital. (Poland)

HCV infection outbreak was registered: 8 patients, 291 exposed persons

• Common exposure was CT scan with contrast

• Mechanism of infection transmission was not clearly identified, however, instructions for use, actions of the device and the activities of people who worked with device pointed to multiple deficiencies, on the part of the manufacturer and the hospital

• From hospital, there was no risk assessment for the device used, no device decontamination procedures developed, and no regular staff training

Balmelli et al., 2020 [28]

To describe a case of HCV transmission from a chronic asymptomatic carrier to four patients through intravenous lines for contrast medium at an acute hospital

CT with contrast media, acute hospital. (Switzerland)

Patients (n = 14) HCV antibodies, presence of HCV RNA

Four patients who underwent contrast-enhanced computed tomography (CT) scanning were infected with HCV from a contaminated multi-dose vial of Sodium Chloride

• Procedures that do not guarantee sterility: Routine insertion of a needle at the top of the vial to facilitate aspiration of the 0.9% sodium chloride solution was observed; the use of a 100-mL multi-dose vial of 0.9% sodium chloride to flush the intravenous lines of several patients before injection of contrast medium was found to be connected with outbreak. Approximately 10 mL of 0.9% sodium chloride was used for each patient, and a single vial lasted for eight to nine consecutive patients

• Human error: It is hypothesised that a healthcare worker may have erroneously used the same syringe twice on a patient because of difficulties flushing the line or to set another one

• Interviews with all involved healthcare workers revealed that none reported to undertake such behaviour, however, some of them did not consider the use of the same syringe twice on the same patient to be as wrong as using it on two different patients

Sarvananthan et al., 2021 [29]

To investigate the rates of incident reporting in a MID

Large academic health science centre. (Canada)

Hospital’s electronic incident report database. Incident report forms, n = 665 (July, 2018–July, 2019)

Incident report rate (Discussion focused on top 4 incident types, which did not include infection control)

• Infection control was one of 14 incident type categories in a MID, accounting for 1.35% of incidents. Example: tuberculosis suspected in a patient, but patient arrived at MID without mask

• Concerns about underreporting; need standardisation of incident reporting and reduced barriers to reporting, to improve the safety incident report system’s effectiveness

• Weekly quality conversations and selecting a modality-specific safety representative

Yu et al., 2021[30]

Retrospective analysis of 2 cases of healthcare-associated COVID-19 transmission in 2 radiology departments, compared to the IPC practices in department, where no COVID-19 transmission occurred

Radiology department (China)

2 cases of health-care-associated COVID-19 transmission in 2 radiology departments

• Loopholes in IPC practices due to poor understanding of the COVID-19, need to establish isolation zones and additional sterilisation zones