Towards Safer Radiotherapy

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Director, National Institute of Health Research Centre for Patient Safety and Service Quality Mr Jerry Williams (British Institute of Radiology) Consultant Medical Physicist Royal Infirmary, Edinburgh Dr Michael Williams (The Royal College of Radiologists) Vice-President, The Royal College of Radiologists Consultant Clinical Oncologist, Oncology Centre Addenbrooke’s Hospital, Cambridge Professor Peter Williams (Institute of Physics and Engineering in Medicine) Director, North Western Medical Physics Christie Hospital, Manchester 85 Dr Hosney Yosef (British Institute of Radiology) Consultant Clinical Oncologist Beatson West of Scotland Cancer Centre, Glasgow The working party would also like to thank the peer reviewers for their helpful comments on this report. Approved by the Board of the Faculty of Clinical Oncology of The Royal College of Radiologists: October 2007 Approved by the Council of the Society and College of Radiographers: November 2007 Approved by the British Institute of Radiology: November 2007 Approved by the Institute of Physics and Engineering in Medicine: January 2008 Approved by the National Patient Safety Agency: January 2008 Towards Safer Radiotherapy
The Royal College of Radiologists 38 Portland Place London W1B 1JQ Tel +44 (0)20 7636 4432 | Fax +44 (0)20 7323 3100 | Email enquiries@rcr.ac.uk | URL www.rcr.ac.uk | A Charity registered with the Charity Commission No. 211540 Citation details: The Royal College of Radiologists, Society and College of Radiographers, Institute of Physics and Engineering in Medicine, National Patient Safety Agency, British Institute of Radiology. Towards Safer Radiotherapy. London: The Royal College of Radiologists, 2008. On publication, this document will be made available on all the organisations’ websites. ISBN 978-1-905034-25-3. RCR Ref No. BFCO(08)1. © The Royal College of Radiologists, April 2008 This publication is copyright under the Berne Convention and the International Copyright Convention. All rights reserved. For permission to reproduce any of the content contained herein, please email: permissions@rcr.ac.uk This material has been produced by The Royal College of Radiologists (RCR) for use internally within the National Health Service in the United Kingdom. It is provided for use by appropriately qualified professionals, and the making of any decision regarding the applicability and suitability of the material in any particular circumstance is subject to the user’s professional judgement. While every reasonable care has been taken to ensure the accuracy of the material, RCR cannot accept any responsibility for any action taken, or not taken, on the basis of it. As publisher, RCR shall not be liable to any person for any loss or damage, which may arise from the use of any of the material. The RCR does not exclude or limit liability for death or personal injury to the extent only that the same arises as a result of the negligence of RCR, its employees, Officers, members and Fellows, or any other person contributing to the formulation of the material. Design by innov8 graphic design: www.innov8gd.com. Printed by Latimer Trend.
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IPEM Patient Safety Division The Ro
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Foreword In my Annual Report on the
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• This report contains detailed r
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Chapter 2: Nature and frequency of
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technology tends to impair individu
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Table 2.1. Examples of radiation in
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2.3.3 There was an average of 30 in
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Table 2.5. Errors with > 10 Gy than
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Chapter 3: Defining and classifying
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Near miss Other non-conformance A p
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22 Table 3.1. Examples of classific
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Chapter 4: Prerequisites for safe d
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• The multidisciplinary team of p
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Recommendation All procedures shoul
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The audit process should ideally:
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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 and 82: Abbreviations 82 BIR BSI CNS CPD CT
Page 83: Membership of Working Party Ms Geri
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