Towards Safer Radiotherapy

6.2.1.b Voluntary reporting systems
In a voluntary reporting system, no penalties are imposed for not reporting. Generally,
the severity of incidents reported under such a system is relatively low, with patients
suffering little or no injury. Most of the reported episodes are ‘near misses’; errors that
are detected before starting treatment and before harm can occur.
For every reportable radiation incident, many more near misses or incidents resulting
in minimal harm occur. Figure 6.2 shows a diagram originally used in 1931 by Herbert
Heinrich, a pioneer of industrial safety, to illustrate the fact that in the workplace, for
every fatal incident, there were 30 minor and 300 near misses. 93 Root cause analysis
of the minor events and near misses has been shown to provide valuable lessons,
which can prevent serious incidents.
Therefore, voluntary, non-statutory reporting systems offer the potential to build a
large database of near misses and incidents of low severity, and these data can then
be available for analysis and learning by the radiotherapy community in the UK and
worldwide.
50
Figure 6.2 Heinrich’s triangle 93
Major accident/fatality
Minor injury
Near miss
6.2.2 Current voluntary reporting systems in the UK
Currently, voluntary reporting is available in England and Wales through the NPSA. Reports
to the NPSA are derived from across all areas of healthcare and are by no means exclusive to
radiotherapy.
The ROSIS database is a European collaborative which collects and analyses errors and near
misses, but to function fully a long-term guarantee of resources is required, which is difficult
for an international venture to secure. 92
6.3 Proposed voluntary UK radiotherapy reporting, analysis and learning system
The importance of widespread reporting and learning from mistakes was highlighted by the NHS in
the publications An organisation with a memory 94 and Building a safer NHS for patients, 95 which
first announced the establishment of the NPSA.
Currently, the NPSA collects data on radiotherapy incidents, which occur in England and Wales, but
does not have the dedicated specific expertise to analyse data related to radiotherapy. Also, the
wide variation in the way in which the errors are recorded means that meaningful analysis must
include review of free text of individual incidents. Therefore, the Radiation Protection Division of the
Towards Safer Radiotherapy