Towards Safer Radiotherapy

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Table 2.2. Example of a radiation underdose incident reported to Department of Health after May 2000 Centre C Incident 132 patients received doses lower than intended (including 20 patients 5–10% and 5 patients >10% lower than intended) Error Incorrect application of wedge factor Underlying cause Misunderstanding of the meaning of the wedge factor for asymmetric, dynamically wedged beams when the dose prescription point is not on the central axis Contributory factors Complexity of process 2.3 Incidents reported under IR(ME)R 2000 in England, Scotland and Wales 2.3.1 The appropriate authorities in England, Wales and Scotland have permitted this working party to carry out an analysis of their anonymised data on incidents reported under IR(ME)R 32 between May 2000 and August 2006. This is the first time these data have been published. 13 2.3.2 During this period, 181 incidents involving radiotherapy were reported under IR(ME)R to the appropriate authority in England, Scotland and Wales. The numbers reported each year are given in Table 2.3a and outlined in Table 2.3b. Table 2.3a. Annual numbers of incidents reported under IR(ME)R in UK Period May–Dec 2000 7 2001 13 2002 19 2003 36 2004 32 2005 35 Jan–Aug 2006 39 Total 181 No. of incidents Table 2.3b. Outline of causes of the 181 radiation incidents reported under IR(ME)R Cause Incorrect referral information 5 Patient identification error 4 Element of the design or delivery of an individual treatment 167 Inadvertent exposure of a foetus 3 Equipment error rather than human error (and therefore reportable to Health and Safety Executive) Total 181 No. of incidents 2 Towards Safer Radiotherapy
2.3.3 There was an average of 30 incidents reported per year from the 60 radiotherapy departments in the UK; that is, an average of three reported incidents per department during 2000–06. 2.3.4 One incident was an underexposure and as such there was no legal requirement to report it. 2.3.5 Three incidents involving the unintended exposure of a foetus throughout a radical treatment course also did not technically need to be reported, as protocols were in place and had been followed. In each case, it had been documented that before treatment the patients had been asked their current pregnancy status and advised they should avoid becoming pregnant during treatment. In each case, the patient failed to disclose her pregnancy to treatment staff. 2.4 Analysis of incidents reported under IR(ME)R in England, Scotland and Wales 2.4.1 A number of key features should be noted. • All reported incidents were investigated by the appropriate IR(ME)R authority. Subsequently, the healthcare organisation was required to put systems in place locally to minimise the risk of such an event occurring again. 14 • In about 80% of the 181 cases, the patient was not expected to suffer any adverse clinical effects from the error. • Three incidents occurred as a result of a patient not being identified correctly on one single visit (fraction) for treatment, which was part of a longer course. • Four incidents involved systemic failures that affected the treatment of more than one patient. The numbers of patients who potentially could have experienced adverse clinical effects due to the error were four, 11, 14 and 132 patients respectively. In all cases the clinical impact of the errors was small. • Over 90% of incidents were attributed to an error in carrying out a practical aspect of the treatment design, preparation or delivery. • The other 10% occurred as a result of a failure to supply correct details at referral or an incomplete or erroneous treatment prescription. 2.4.2 Two examples of incidents that have been reported and investigated under IR(ME)R by the appropriate authority are described briefly in Table 2.4. Towards Safer Radiotherapy
Page 1 and 2: IPEM Patient Safety Division The Ro
Page 3 and 4: Foreword In my Annual Report on the
Page 5 and 6: • This report contains detailed r
Page 7 and 8: Chapter 2: Nature and frequency of
Page 9 and 10: technology tends to impair individu
Page 11: Table 2.1. Examples of radiation in
Page 15 and 16: Table 2.5. Errors with > 10 Gy than
Page 17 and 18: Chapter 3: Defining and classifying
Page 19 and 20: Near miss Other non-conformance A p
Page 21 and 22: 22 Table 3.1. Examples of classific
Page 23 and 24: Chapter 4: Prerequisites for safe d
Page 25 and 26: • The multidisciplinary team of p
Page 27 and 28: Recommendation All procedures shoul
Page 29 and 30: The audit process should ideally:
Page 31 and 32: tendering process in which the radi
Page 33 and 34: In addition to these scientific and
Page 35 and 36: Recommendation The precise details
Page 37 and 38: 5.6 Verification and checks of trea
Page 39 and 40: known discrepancies between clinici
Page 41 and 42: However, at the present time and in
Page 43 and 44: Staff should be provided with some
Page 45 and 46: Recommendation Each radiotherapy ce
Page 47 and 48: Chapter 6: Learning from errors Tho
Page 49 and 50: 6.2.1.b Voluntary reporting systems
Page 51 and 52: To avoid incorrect speculation and
Page 53 and 54: 7.1.4 Some errors may require a ret
Page 55 and 56: • Externally: Patients should use
Page 57 and 58: Summary of recommendations Departme
Page 59 and 60: 28. Commissioning of radiotherapy e
Page 61 and 62: 62 3b 3c 3d 3e 3f 3g 3h 3i 3j 3k 3l
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9 Mould room/workshop activities 64
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13 Treatment unit process 66 13a 13
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16f 16g Communication of follow-up
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Appendix 6.1. Care delivery problem
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15. Girinsky T, van der Maazen R, S
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52. Society and College of Radiogra
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88. Appleyard R, Ball K, Hughes FE
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Glossary of terms 78 Anthropomorphi
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80 In vivo dosimetry Isocentric Iso
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Abbreviations 82 BIR BSI CNS CPD CT
Page 83 and 84:
Membership of Working Party Ms Geri
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The Royal College of Radiologists 3
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Towards Safer Radiotherapy

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