Towards Safer Radiotherapy

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5e 5f 5g 5h 5i 5j 5k 5l Completion of radiation-specific information Completion of details of other professionals Completion of administrative data Recording of previous treatment details Recording of patient’s specific requirements Recording of non-standard information/protocol variations Authorisation to irradiate (IR(ME)R) Other 6 Booking process (pretreatment and treatment) 6a 6b 6c 6d 6e Bookings made according to protocol Bookings made according to request details Recording of booked appointments Communication of appointments to patient Other 63 7 Processes prior to first appointment 7a 7b 7c 7d 7e 7f 7g 7h New patient: registration with healthcare organisation’s PAS New patient: registration with department PAS New patient: generation of notes Old patient: location of healthcare organisation’s notes Old patient: location of department notes/previous treatment details Availability of reports/imaging required by protocol for treatment Availability of consent documentation Other 8 Pretreatment: preparation of patient 8a 8b 8c 8d 8e Confirmation of ID Confirmation of consent Confirmation of fertility/pregnancy status Advice on procedure Other Towards Safer Radiotherapy
9 Mould room/workshop activities 64 9a 9b 9c 9d 9e 9f 9g 9h 9i 9k 9l Confirmation of ID Pre-mould room diagnostics/interventions Production of immobilisation devices Checking/fitting of immobilisation devices Production of other accessories/personalised beam shaping device Checking of other accessories/personalised beam shaping device Labelling of mould room/workshop outputs Recording of information in patient record Instructions to patient End of process checks Other 10 Pretreatment activities/imaging (to include CT, simulation, clinical mark-up) 10a 10b 10c 10d 10e 10f 10g 10h 10i 10j 10k 10l 10m 10n Confirmation of ID Positioning of patient Localisation of intended volume Production of images using correct imaging factors Production of images using appropriate field sizes Production of images demonstrating correct detail Labelling of images Saving of planning geometry data Recording of radiation data Documentation of instructions/information Marking of patient or immobilisation device End of process checks Identification of staff Other 11 Pretreatment planning process 11a 11b Verification of patient ID to include all patient data, imaging etc Recording of patient ID on plan 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 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
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: 62 3b 3c 3d 3e 3f 3g 3h 3i 3j 3k 3l
Page 65 and 66: 13 Treatment unit process 66 13a 13
Page 67 and 68: 16f 16g Communication of follow-up
Page 69 and 70: Appendix 6.1. Care delivery problem
Page 71 and 72: 15. Girinsky T, van der Maazen R, S
Page 73 and 74: 52. Society and College of Radiogra
Page 75 and 76: 88. Appleyard R, Ball K, Hughes FE
Page 77 and 78: Glossary of terms 78 Anthropomorphi
Page 79 and 80: 80 In vivo dosimetry Isocentric Iso
Page 81 and 82: Abbreviations 82 BIR BSI CNS CPD CT
Page 83 and 84: Membership of Working Party Ms Geri
Page 85: The Royal College of Radiologists 3
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Towards Safer Radiotherapy

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