Public Health England patient safety
initiatives in radiotherapy across the UK Helen Best
Although error within radiotherapy is rare, when it does occur the consequence can be significant. With this in mind it is essential for the radiotherapy community to remain aware of the associated risks, avoid complacency and work within a 'safety culture' which underpins practice.
P atient safety has been defined as avoiding harm from the care that is intended to help1 safe form of treatment for cancer2 .
To maintain or improve patient safety, error has to be prevented, or minimised. When the opportunity for error is weighed against the incidence of error, radiotherapy may be seen as a .
National patient safety initiatives The UK has established an international reputation for its safety initiatives in radiotherapy. One of these initiatives is the voluntary reporting of and learning from radiotherapy errors and near misses. A total of 100% of current UK NHS radiotherapy providers have now shared radiotherapy error reports for inclusion in this initiative. In this post-Francis report3
era the focus on learning from errors is likely to continue, as
clinical departments are encouraged and even mandated, to participate in initiatives such as this. After a number of high profile errors4
, the Chief Medical Officer (CMO) for England launched and funded
a range of initiatives relating to patient safety in radiotherapy in 2006. This included the introduction of a dedicated resource within the Health Protection Agency (now Public Health England [PHE]) to support the radiotherapy community in improving patient safety. Radiotherapy staff at PHE provide independent advice on patient safety and process efficiency in clinical practice across the radiotherapy community. This includes advice to healthcare professionals, members of the public and inspectorates. A further initiative by the CMO resulted in a joint publication by the professional bodies in 2008, entitled Towards Safer Radiotherapy5
(TSRT), which set out key recommendations to improve patient safety in
radiotherapy. These recommendations to improve patient safety in reporting, analysing and learning from radiation incidents and near misses, were established so that all radiotherapy centres should participate
-6- Dissemination of learning Dissemination of learning is done in a number of ways. These include a series of publications, including the
in this, enabling national learning. The Patient Safety in Radiotherapy Steering Group (PSRT) was tasked with taking this forward. This multidisciplinary group’s membership includes representatives from PHE, Society and College of Radiographers (SCoR), Royal College of Radiologists (RCR), Institute of Physics and Engineering in Medicine (IPEM), and a patient representative. PHE also provides independent advice on patient safety in clinical practice. Interaction with clinical departments depends on the needs of the individual department. This can range from an email or telephone call to a clinical site visit. These visits are at the department’s invitation and intended to provide independent on-site support and reassurance on issues surrounding patient safety and process efficiency, within the context of the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R). IR(ME)R is legislation intended to protect the patient from hazards associated with ionising radiation.
Reporting and learning from errors and near misses The radiotherapy reporting and learning system is a feedback process. Radiotherapy departments across the UK report errors and near misses locally. Classification and pathway coding from TSRT is also assigned by local departments. The classification enables the error to be graded into one of five severity classifications. The departments also code the error, indicating the point in the patient’s pathway where the event occurred. Reports from NHS departments are submitted from England and Wales to the National Reporting and Learning System (NRLS) of NHS England, and directly to PHE from Northern Ireland and Scotland. Departments are encouraged to report all classifications of incidents on a monthly basis to allow timely feedback. This voluntary system is not a substitute for legal requirements to report to the appropriate authorities all patient exposures deemed much greater than intended. The data are then interrogated to produce trend analyses for national learning. These can be in the form of publications, presentations and clinical site visits. The analysis is reviewed by the PSRT whose comments are incorporated into learning publications. The analysis and data are then used by clinical departments and others to learn and feed into the prevention of recurrence.
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