Towards Safer Radiotherapy

Table 2.5. Errors with > 10 Gy than the dose intended over course of treatment
16
Cause
Wrong side/site being planned or wrong prescription 7
Technical complexity and unintended overlap of concomitant
treatment areas
Patient changing position after set-up by therapeutic
radiographers
Error in calculation
− failure to interpret prescription correctly
− failure to use the correct data or input the correct dose per
fraction into the planning computer
Incorrect manual data entry into the LinAc Record & Verify (R&V)
system
Incorrect set-up details being recorded at treatment preparation
stage
Incorrect interpretation of, or failure to follow, patient set-up
details on the LinAc
Total 29
Number
2
1
5
4
3
7
2.5 Risk to patients of an adverse incident during radiotherapy treatment delivery
2.5.1 To place the number of incidents in context, it is necessary to consider the numbers of
courses and fractions of treatment delivered. There are no definitive data on radiotherapy
activity within the UK for the period covered by this review (2000–06). However, a survey
conducted by the RCR showed that in England, in 2005, 110,344 patients were prescribed
1,414,192 fractions. 8 Validation was obtained from the Radiotherapy Episode Statistics (RES)
project. A sample of activity for the financial year 2004–05 from 36 English centres allows an
estimate for the whole of England of 107,219 patients prescribed 1,503,474 fractions. 34 The
RES figures are in line with the RCR findings. Scaling these figures to include Scotland, Wales
and Northern Ireland, the total courses and fractions for the UK in 2004–05 were
approximately 130,000 and 1,740,000 respectively. 8
2.5.2 The 181 incidents reported in the UK during the first 6.3 years of IR(ME)R being in place
affected 338 patients. Based on a figure of 130,000 courses of radiotherapy delivered
annually, this equates to a reported incidence rate of approximately 40 per 100,000 courses
of radiotherapy. Of these, 24 (all involving >10 Gy above the dose prescribed) were predicted
to result in an adverse clinical outcome for the individual patients, which equates to around
3 per 100,000 courses of radiotherapy.
2.5.3 It is recognised that the data presented here may not fully represent the rate of clinically
significant radiotherapy errors. There may be under-reporting of incidents and significant
errors involving doses much less than intended are not reportable under IR(ME)R. 32 There
may also have been error due to equipment failure that would have been reported to the
Health and Safety Executive (HSE) under the Ionising Radiations Regulations 1999 29 (IRR99)
rather than IR(ME)R. 32
2.5.4 Safety is a concern across the whole of healthcare not only within the UK but worldwide. It is
reported that 10% of people who receive healthcare in industrialised countries will suffer
Towards Safer Radiotherapy