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Towards Safer Radiotherapy

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Recommendation<br />

Following a level 1 or 2 radiation incident, a systematic investigation should be conducted to<br />

identify the root causes. To prevent recurrence, the lessons learnt from root cause analysis<br />

should be disseminated locally and through a national anonymised learning system.<br />

6.1.2 A well-designed quality system should not only learn from local incidents, but also<br />

implement best practice from national and international sources such as:<br />

• Notifications of safety issues in England can be transmitted via the Safety Alert<br />

Broadcast System (SABS), which are issued by the Medicines and Healthcare products<br />

Regulatory Agency (MHRA – Devices), the Department of Health Estates and Facilities<br />

and the NPSA<br />

• Recommendations from published inquiries into radiotherapy incidents, such as those<br />

that occurred in Exeter, North Staffordshire Royal Infirmary and Glasgow and the<br />

recommendations published by the RCR, IPEM and SCoR in response to these incidents<br />

• Analyses of radiotherapy incidents from around the world, such as those published by<br />

the Radiation Oncology Safety Information System (ROSIS), 92 the International Atomic<br />

Energy Agency (IAEA) 36 and the ICRP. 81<br />

49<br />

Recommendation<br />

Each radiotherapy centre must operate a quality system, which should ensure best practice<br />

is maintained by applying lessons learnt from radiotherapy incidents and near misses from<br />

other departments as well as in-house.<br />

6.2 National learning<br />

Though local reporting, investigation and learning following an incident is important, other<br />

radiotherapy centres may be equally vulnerable to the same problems. Therefore, the transfer of the<br />

knowledge acquired is also an important step to make radiotherapy safer across the country and<br />

internationally.<br />

6.2.1 National reporting systems<br />

Reporting systems can be divided into two types – statutory and voluntary.<br />

6.2.1a Statutory reporting system<br />

In a statutory system, the reporting of defined incidents is required by law and not to<br />

report would be a criminal offence. There are two functions of statutory reporting<br />

systems.<br />

1. They provide assurance that serious incidents, resulting in harm or death to<br />

patients, are reported, investigated and that appropriate action is taken to<br />

prevent recurrence.<br />

2. They encourage radiotherapy centres to improve the safety of their radiotherapy<br />

practice by increasing accountability.<br />

As discussed in Chapter 2, in the UK, statutory reporting is required under UK law by<br />

both IR(ME)R 2000 32 and the IRR99. 29<br />

<strong>Towards</strong> <strong>Safer</strong> <strong>Radiotherapy</strong>

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