Towards Safer Radiotherapy

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NPSA NRAG PAS PPM PTV QA QART RI R&V RCR RES ROSIS SABS SCoR SOPS SpR TLD TPS 3D National Patient Safety Agency National Radiotherapy Advisory Group Patient administration system Planned preventative maintenance Planning treatment volume Quality assurance Quality assurance in radiotherapy Radiation incident Record and verify The Royal College of Radiologists Radiotherapy Episode Statistics Radiation Oncology Safety Information System Safety alert broadcast system Society and College of Radiographers Standard operating procedures Specialist registrar Thermoluminescent dosimetry Treatment Planning System Three dimensional 83 Towards Safer Radiotherapy
Membership of Working Party Ms Geri Briggs (Society and College of Radiographers) Quality Manager Berkshire Cancer Centre Royal Berkshire NHS Foundation Trust Mr Steve Ebdon-Jackson (Health Protection Agency) Head of the Medical Exposure Department, Radiation Protection Division Health Protection Agency 84 Dr Sara C Erridge (The Royal College of Radiologists, Chair) Consultant Clinical Oncologist and Honorary Senior Lecturer in Radiation Oncology Edinburgh Cancer Centre, Edinburgh Mr Michael Graveling (Society and College of Radiographers) President-Elect of Society and College of Radiographers Radiographer, Sheffield Teaching Hospitals NHS Foundation Trust Mr Stephen Hood (Patient representative) Lay member of Clinical Oncology Patients’ Liaison Group, The Royal College of Radiologists Dr Alan McKenzie (Institute of Physics and Engineering in Medicine) Director of Medical Physics and Bioengineering United Bristol Healthcare NHS Trust Ms Carol Nix (Health Protection Agency) Medical Exposure Department Health Protection Agency Dr Ben Thomas (National Patient Safety Agency) Safer Practice Lead National Patient Safety Agency Professor Charles Vincent (Patient Safety Expert) Professor of Clinical Safety Research, Imperial College, London Towards Safer Radiotherapy
Page 1 and 2:
IPEM Patient Safety Division The Ro
Page 3 and 4:
Foreword In my Annual Report on the
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• This report contains detailed r
Page 7 and 8:
Chapter 2: Nature and frequency of
Page 9 and 10:
technology tends to impair individu
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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
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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 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: Abbreviations 82 BIR BSI CNS CPD CT
Page 85: The Royal College of Radiologists 3
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Towards Safer Radiotherapy

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