The Role of the HPA in Advancing

Patient Safety in Radiotherapy

EORTC ROG - RT Technologists Section

Úna O’Doherty
Senior Clinical Radiotherapy Officer
Medical Exposures Department

6th November 2008

Publications on Patient Safety in

Radiotherapy

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CMO Report 2006

Health Protection Agency

(HPA)

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 Senior Clinical Officer in Radiotherapy

• Independent resource for the radiotherapy community with

the goal of improving patient safety and efficiency in
radiotherapy departments:

1. Analysis of radiotherapy incidents, whether near misses or reportable

events and promulgation of experience across the community
2. On site support to individual departments
3. Work with professional bodies to provide guidance on good practice

– Liaise with UK professional bodies & international organisations

– Liaise with manufacturers & suppliers
– Liaise with education providers

Why work to improve patient safety in

radiotherapy?

•Incorrect decay data (USA) •Accelerator interlock failure

•Erroneous use of TPS (UK)
•Accelerator software problems
(USA & Canada)
•Computer file not updates (USA)
•Incorrect repair of accelerator
(Spain)
•Miscalibration of beam (Costa
Rica)
•Lack of procedures for acceptance
of TPS (UK)
(Poland)
•HDR unit malfunction (USA)
•Incorrect manual parameter
transfer (UK)
•Reversal of images (USA)
•Inappropriate measuring device
(France)
•Erroneous calculations of soft
wedges (France)
•Error in TPS data entry (Panama)

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1. Analysis of Radiotherapy Incidents

Analysis shows that the

factors contributing to
incidents are not unique.
unique
If the experience in one
department could be shared
broadly across the
community some of the
lessons learned could be
Heinrich’s Accident Triangle
implemented more widely,
thus potentially reducing the Heinrich HW. Industrial accident prevention; a
number of incidents.
incidents scientific approach, 1st edn. New York:
McGraw-Hill Book Company, Inc., 1931.

1. Analysis of Radiotherapy Incidents

Geri Briggs

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1. Analysis of Radiotherapy
Incidents

1. Analysis of Radiotherapy Incidents

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1. Analysis of Radiotherapy Incidents

1. Analysis of Radiotherapy Incidents

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1. Analysis of Radiotherapy Incidents

http://www.npsa.nhs.uk/nrls/patient-safety-incident-data/quarterly-data-reports/

1. Analysis of Radiotherapy Incidents

Currently writing guidance …..

• Improve RT error reporting quantity to & quality to NRLS
• Ensure RT error reports are classified and coded according to TSRT
at source
• Ensure consistency of this classification and coding
• Produce Self Assessment Audit tool for Towards Safer Radiotherapy

Goal
• Produce meaningful analysis from RT error reports
• Feedback results of analysis to RT community

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 1. Analysis of Radiotherapy Incidents
Future Work
•Add inspectorate incident data
•Contribute to international reporting
and learning
• Develop additional coding for causes
of errors

2. On site support to
radiotherapy departments

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2. On site support to
radiotherapy departments

Example of Site
Visit Itinerary

Focus on patient
pathway and data
flow through the
department

2. On site support to individual

departments
Example of good practice observed

‘Site
Site specific protocols are in use in the CT scanner,
scanning levels defined for different anatomical sites, DLP
numbers and number of slices recorded.
recorded
DRLs are already in use evidencing good practice.
Procedures for verifying left from right in safety critical
images were in use’.

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2. On site support to individual
departments
Examples of advice given following consultation with
departmental representative

‘Further immobilisation of most patient setups. Where couch

indexing is not available, couch height, lateral and
longitudinal could be captured on day one.one.
Commissioning on machine parameters for individual
technique tolerances could then be tightened.
This might then reduce the probability of an incorrect field
displacement occurring’.

2. On site support to individual

departments

The Future
•Review of past site visits
•Stakeholder Meeting in Jan 2009
Invite representatives of those departments visited / planned
Examine if expectations met
Discuss how / if possible to increase the value of site visits and their
future development

•Feedback will inform future site visits

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3. Work with professional bodies to
provide guidance on good practice

Contact Details

Una.Odoherty@hpa.org.uk

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