Reporting and learning survey To learn more about error reporting and how lessons are learnt from local and national analysis, a survey was disseminated in 2014, to all radiotherapy service providers across the UK. The aim of this survey was to build on knowledge gained from previous surveys published in 2008 and 2011, and establish an understanding of trends in reporting and learning cultures. The full analysis of this survey is freely available online7
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This survey investigated reporting and learning at a local and national level. Amongst the survey questions, departments were asked how the national analysis of radiotherapy errors was used as a learning tool. The most common response was to share the analysis at meetings (82.1% n = 32), followed by the comparisons of local versus national trends (64.1% n = 25). The most frequent methods are shown in figure 3. Only 12.8% (n = 5) of respondents stated that just one method was used. A common theme was the sharing of the newsletter with staff either as a hard copy or via the department computer network. Of the 92.7% (n = 38) respondents that stated that the newsletter was used as a learning tool, only 23.7% (n = 9) shared this tool with all staff members. It was shared with a cross-section of staff, including radiographers (65.8% n = 25), physicists (47.7% n = 18) and doctors (18.4% n = 7). Only 15.8% (n = 6) of departments shared this newsletter with radiographers only. The newsletter is shared with all heads of service and designed to disseminate learning from radiotherapy error reports to professionals across the radiotherapy community. The UK radiotherapy communities' continued commitment to improving patient safety, is reflected in the reporting of radiotherapy errors. Ideas and suggestions for improvements to this publication are always gratefully received and should be sent to
radiotherapy@phe.gov.uk.
Future work Many will be aware that the revised basic safety standards directive was published as Council Directive 2013/59/Euratom8
in the Official Journal of the European Union last year. New regulations will be required
by February 2018 to transpose the new directive. This will provide departments with a new instrument for maintaining patient safety in radiotherapy. It is imperative that radiotherapy error trends continue to be reported, analysed and monitored on a
cyclical basis, in order to inform ongoing safe and effective radiotherapy practice. This is especially pertinent as new techniques and technologies are implemented, and as new clinical radiotherapy departments are established. This work supports a risk-based approach to improving safety, both locally and nationally and indicates a culture that is open, transparent and already present in the UK radiotherapy community. Work continues on the development of the national reporting and learning from radiotherapy errors, including the development of a causative factor taxonomy and a review of the patient pathway coding.
Conclusion All current UK radiotherapy NHS departments have participated in the radiotherapy voluntary reporting and learning system. This is entirely consistent with the Department of Health’s drive for a more open and honest patient safety culture across the NHS, and enacts recommendations from the Francis report on openness, transparency and candour. The continued collaboration between these departments and PHE will serve to
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