InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

EFOMPapproachtoreducingerrors
inRadiotherapy
HermanvanKleffens
and
WilvanderPutten
Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

OldExamples

USA,
1985,Therac25

Spain,
1990,Zaragoza

UnitedKingdom,
1988,Exeterand
1991,NorthStaffordshire

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

Zaragoza
Radiation error
causes 18 deaths

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

North
Staffordshire

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

NorthStaffordshire,analysis
1982ImplementationofRTPLAN
ManualcorrectionforSID
1991ImplementationofCADPlan
Underdoseof19%for90cmand36%for80cm
SSD!
1045Patientsinvolved;adverseeffectpossiblein
492patients(401dead)

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

Exeter

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

Logbook

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

Exeter,analysis
CalibrationerrorafterrenewalCo60source
3,5months:Skinreactions=>calibrationcheck
Intercomparison=>calculationerror
5months:207patients25%higherdose
NoindependentcalculationbyanotherMP
Inadequateinvestigationafterunusualskin
reactions
Organisationalimprovementsrequired

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

1977
TENERIFE
583 FATALATIES

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

GeneralRecommendations
Dosecalculationsshouldbeperformedwithtwo
independentsystemsusingdifferentcalculation
methods(NCSreport11)
Criticalactionsshouldbeperformedbytwo
differentindividuals.Controlofanactionby
anotherindividualisnotadequate(ASU).

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

Howtoimprove
Opencultureforreporting(near)errors
Criticalactions(measurements/calculations,
commissioning,setupequipment,etc.)shouldbe
performedtwicebydifferentpersons
Adequate(repeating)instructions
EstablishmentofTotalQualitySystemsincluding
aSafetyManagementSystem
RiskAnalysis
Preventivemeasures
Goodeducationofprofessionals!
Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

EFOMPapproach
PolicyStatements(PS)

No1MedicalPhysicsEducationandTraining,1984
No3RadiationProtectionofthepatientinEurope,1988
No8ContinuingProfessionalDevelopmentfortheMP,1998
No9RadiationProtectionofthePatientinEurope,1999
No12PresentStatusofMPEducationandTrainining,2009
No13RecommendedGuidelinesontheDevelopmentof
SafetyandQualityManagementSystemsforMPDepts,2010

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

EFOMPapproach
PSNo12ThepresentstatusofMedicalPhysicsEducationand
Trainingin Europe.NewperspectivesandEFOMP
recommendations.
AllNMOsshouldestablisha5yearMasteronMedicalPhysics
(orequivalent)andaminimumof2yearpostgraduate
traininginMP=>QMP.
Aftera5yearCPDcycle=>SMP.
Obligatoryfor2reasons:
1. Bolognadeclaration
2. EuropeanDirective2005/36/EC
Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

EFOMPapproach
PSNo13RecommendedGuidelinesontheDevelopmentof
SafetyandQualityManagementSystemsforMPDepts
Aims:
a)Increasethesafetyofthepatientundergoingdiagnostic
andtherapeuticproceduresrelatedtomedicalphysics
b)Increasethesafety,qualityandefficiencyofthemedical
physicsservices
c)Introducetheconceptofimprovementandupgrading
ofthemedicalphysicsservices.

Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

SchoolforMedicalPhysicsandEngineering
inEindhoven(SMPE/e)

Formallyestablishedin2006andcontinueseducationofQMP
whichwasstartedinEindhovenin1990.
BylawonlySMP(9yeareducationalperiod)recognized.
AlltraineesareeducatedinSafetyandRiskAnalysis(startin
2001).
DedicatedsessionofInternationalEFOMPcongressonSafety
andRiskAnalysisin2003
EFOMPworkshoponSafetyandRiskAnalysisin2004.
AssistedwithestablishmentofaSafetyandRiskAnalysiscourse
inNUIGalwayinIrelandin2004(runannuallyaspartofMSc
inMedicalPhysicsthere)
ContributiontoDSMFsymposiumin2005
Versailles, France
December 2 4, 2009

InternationalConferenceonModernRadiotherapy:

Advances and Challenges in Radiation Protection of Patients

SummaryConclusion
EFOMPrecommendsimplementationofformal
Safetymanagementsystemsformedicalphysics
EFOMPadvocatesthatallNMOsshouldincorporate
acourseinSafetyandRiskAnalysisintheeducation
andtrainingofMedicalPhysicists.
EFOMPbelievesthattheseactionswillleadtoa
reductionoferrorsinHealthCareingeneraland
Radiotherapyinparticular.

Versailles, France
December 2 4, 2009