Towards Safer Radiotherapy

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13dd 13ee 13ff 13gg 13hh 13ii 13jj Communication between treatment unit and V&R Recording of patient attendance Recording of delivered treatment data Recording of additional information End of process checks Identification of responsible staff Other 14 On-treatment review process 14a 14b 14c 14d 14e On-treatment review of patient according to protocol by RT staff On-treatment review of patient according to protocol by other professional On-treatment review of notes/data to according protocol Actions following on-treatment review Other 67 15 Brachytherapy 15a 15b 15c 15d 15e 15f 15g 15h 15i 15j 15k Ordering of sources Delivery of sources Source calibration Sterility of sources Correct applicators/sources Correct theatre equipment Initial positioning of applicators/sources Planning of treatment Maintenance of position of applicators/sources Removing of applicators/sources Other 16 End of treatment process 16a 16b 16d 16e Communication of appropriate end of treatment information to patient Recording of treatment summary information in notes Communication of information to referring clinician/GP/CNS etc Organisation of follow-up appointment to protocol Towards Safer Radiotherapy
16f 16g Communication of follow-up to patient Other 17 Follow-up process 17a 17b 17c Follow-up consultation and documentation Management of non-attendance Archiving of details of treatment 18 Timing Other activities contributing to protocol violations 18a 18b Timing of chemo/irradiation Transport issues 68 18c Portering issues 19 Document management 19a Availability of current protocol documentation 20 Staff management 20a Availability of staff with competency appropriate to procedure 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 and 64: 9 Mould room/workshop activities 64
Page 65: 13 Treatment unit process 66 13a 13
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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