Towards Safer Radiotherapy

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11c 11d 11e 11f 11g 11h 11i 11j 11k 11l 11m 11n 11o 11p 11q 11r 11s 11t 11u 11v Importing of data from external administrative sources Importing of data from external imaging sources Choice of data Choice of dose and fractionation inputs Availability of source data Choice of technique Target and organ at risk delineation Generation of plan for approval (to include DVH etc as app.) Authorisation of plan Verification of plan/identification of responsible staff Recording of definitive treatment prescription Recording of patient-specific instructions Management of process flow within planning Management of authorisation process Timeliness of plan production Calculation process for non-planned treatments Calculation checking process for non-planned treatments End of process checks Identification of responsible staff Other 65 12 Treatment data entry process 12a 12b 12c 12d 12e 12f 12g 12h 12i Pre-data entry verification Choice of data entry method (input vs transcription) Use of correct data Correct ID of patient/all patient input data Correct ID of patient output data Accuracy of data entry End of process checks Identification of responsible staff Other Towards Safer Radiotherapy
13 Treatment unit process 66 13a 13b 13c 13d 13e 13f 13g 13h 13i 13j 13k 13l 13m 13n 13o 13p 13q 13r 13s 13t 13u 13v 13w 13x 13y 13z 13aa 13bb 13cc Availability/timeliness of all required documentation Patient ID process Patient data ID process Explanation/instructions to patient Confirmation of pregnancy/fertility status Assessment of patient prior to treatment Patient positioning Use of IVD according to local protocol Use of on-set imaging Transfer of marks ID of reference marks Movements from reference marks Setting of treatment machine parameters Setting of collimator angle Setting of jaw position Setting of asymmetry Setting of couch position/angle Use of immobilisation devices Use of beam shaping devices Use of beam direction aids/applicators Use of compensators Use of wedges Availability of treatment accessories Setting of energy Setting of monitor units On-set imaging: production process On-set imaging: approval process On-set imaging: recording process Management of variations/unexpected events/errors 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 and 62: 62 3b 3c 3d 3e 3f 3g 3h 3i 3j 3k 3l
Page 63: 9 Mould room/workshop activities 64
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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