Towards Safer Radiotherapy

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Contents Foreword 4 Executive summary 5 Chapter 1 Introduction 7 Chapter 2 Nature and frequency of human errors in radiotherapy 8 Chapter 3 Defining and classifying radiotherapy errors 18 Chapter 4 Prerequisites for safe delivery of radiotherapy 24 Chapter 5 Detection and prevention of radiotherapy errors 35 Chapter 6 Learning from errors 48 Chapter 7 Dealing with consequences of radiotherapy errors 53 Summary of recommendations 58 3 Appendices Appendix 3.1 61 Appendix 4.1 69 Appendix 6.1 70 References 71 Further reading 77 Glossary of terms 78 Abbreviations 82 Membership of Working Party 84 Towards Safer Radiotherapy
Foreword In my Annual Report on the State of Public Health in 2006, 1 I drew attention to the problem of radiotherapy safety. Overall, radiotherapy in the United Kingdom offers a first-rate service providing high-quality care to the vast majority of patients every year. However, in a number of unfortunate cases over the last few years, overdoses of radiation led to severe harm to patients. It is recognised that these are uncommon events, yet their impact on the patient, staff involved and the wider health service are devastating. Not only does it compromise the delivery of radiotherapy, it calls into question the integrity of hospital systems and their ability to pick up errors and the capability to make sustainable changes. While further investment in radiotherapy is a continuing desirable goal, the patient safety movement has started to establish that changing the culture of an organisation involves steps more sophisticated than just investment and human resources. 4 I am delighted that the inclusion of a key role for the Chief Executive Officer of NHS trusts has been touched upon, in addition to key recommendations about communication and multidisciplinary procedures. We need to strengthen our reporting mechanisms at both a local and national level, and I strongly support the involvement of every staff member in this process. The advent of regular departmental and divisional meetings to review incident reports is a step forward, not just for those that plan action but also for those that communicate mitigating factors to all involved, including the patient. It would appear that in vivo dosimetry offers an opportunity to add another safeguard in the process of care to protect patients and its promotion, in line with the recommendation I made in my annual report in 2006, is to be applauded. We still have not yet mastered the art of harnessing all available knowledge, both national and international, to reduce adverse events in healthcare. This report represents another important effort to achieve this goal and to ensure we give every patient the care they rightfully deserve. SIR LIAM DONALDSON CHIEF MEDICAL OFFICER DEPARTMENT OF HEALTH Reference 1. Sir Liam Donaldson. 2006 Annual Report of The Chief Medical Officer. On the State of Public Health. London: The Department of Health, 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH_076817 (last accessed 8/2/08) Towards Safer Radiotherapy
Page 1: IPEM Patient Safety Division The Ro
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 and 12: Table 2.1. Examples of radiation in
Page 13 and 14: 2.3.3 There was an average of 30 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
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7.1.4 Some errors may require a ret
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• Externally: Patients should use
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Summary of recommendations Departme
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28. Commissioning of radiotherapy e
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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
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Membership of Working Party Ms Geri
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The Royal College of Radiologists 3
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