Towards Safer Radiotherapy Committee

In June 2006 the Towards Safer Radiotherapy Committee multidisciplinary working party was convened by the Royal College of Radiologists (RCR).  The committees remit was to:

• Review the causes of radiotherapy errors and incidents
• Find ways of reducing occurrence of errors
• Increase detection before harm can occur
• Find ways of reporting errors and near misses to the whole radiotherapy community, thereby facilitating knowledge and learning which might prevent repetition
• Make recommendations on the role of education in developing a risk-aware culture.

The work of this committee resulted in the publication ‘Towards Safer Radiotherapy’[2] which introduced a classification and coding system for radiotherapy errors (RTE) along with key recommendations to improve patient safety in radiotherapy.

NPSA Patient Safety in Radiotherapy Steering Group

The work of the NPSA Patient Safety in Radiotherapy Group has been continued and developed by the now Patient Safety in Radiotherapy Group.  A new sharing agreement with the NPSA for RTE has been agreed for the next five years.  The HPA Newsletter 'Safer Radiotherapy' will provide a platform to promulgate learning to the radiotherapy community and to share the analysis undertaken by the HPA of the RTE data collected by the NPSA.

The analysis of the first dataset highlighted areas where further improvements could be made both in terms of quality and quantity of reporting.  Further work was undertaken by the MED and NPSA Patient Safety in Radiotherapy Group on how to implement the TSRT coding and classification within radiotherapy departments and to streamline the submission of data to the NRLS. This work involved:

• Working with the vendor systems used for upload of incident data to the NRLS by radiotherapy departments. 
• Production of a guidance document which was piloted in six radiotherapy departments to explain how to implement the classification and coding system from TSRT and how to improve submission of radiotherapy incidents to the NRLS.
• Launch of guidance document at a national workshop (June 2009) involving all UK radiotherapy departments.
• Towards Safer Radiotherapy: self-assessment tool[3].

 

The HPA has a data sharing agreement with the NPSA to provide the expertise to undertake the analysis of data collected on radiation incidents.  The ‘National Patient Safety Agency (NPSA) Patient Safety in Radiotherapy Group - Report on Activity November 2007 – March 2010’[4],  has been published as a culmination of work and RTE data analysis undertaken by the group.

Patient Safety in Radiotherapy Steering Group

The work of the NPSA Patient Safety in Radiotherapy Group has been continued and developed by the now Patient Safety in Radiotherapy Group.  A new sharing agreement with the NPSA for RTE has been agreed for the next five years.  The HPA Newsletter 'Safer Radiotherapy' will provide a platform to promulgate learning to the radiotherapy community and to share the analysis undertaken by the HPA of the RTE data collected by the NPSA.

Future Initiatives

As technology progresses and radiotherapy techniques change a process for coding revision will be required.  Develop taxonomy to map causative factors and detection methods for RTE to further inform learning within the radiotherapy community.  Discussions have already begun with professional bodies from other healthcare modalities in the UK to share experience of this methodology. In addition the MED are working to establish a link with the international community to enable their work to contribute to international reporting for the benefit of global patient safety.

References

1. Sir Liam Donaldson. 2006 Annual Report of The Chief Medical Officer. On the State of Public Health. London: The Department of Health, 2007.
2. Towards Safer Radiotherapy
3. Towards Safer Radiotherapy: self assessment tool
4. National Patient Safety Agency (NPSA) Patient Safety in Radiotherapy Group - Report on Activity November 2007 – March 2010