Reportable radiation incident
Figure 1: Classification breakdown of reports September to November 2014 (1692 reports).
Non-reportable radiation incident Minor radiation incident Near miss
Other non-conformance 0 100 200 300 400 500 Number of incident reports 600 700
The UK has established an international reputation for its safety initiatives in radiotherapy
newsletter Safer Radiotherapy and supplementary data analysis6 which were established in 2010.
Safer Radiotherapy facilitates the comparison of local and national incidents and the dissemination of learning across the UK radiotherapy community. It includes an update on the work of the PSRT and contains advice on preventing recurring errors in the patient pathway. Guest editorials from across the radiotherapy community highlight contemporary issues surrounding patient safety, but most importantly, the newsletter includes radiotherapy error data analysis. This highlights key messages and trends identified from radiotherapy error reports. Examples of this analysis can be seen in figures 1 and 2. Figure 1 demonstrates the breakdown of reports by classification and figure 2 demonstrates the breakdown of reports by patient pathway coding, showing the main themes across the patient pathway. To date, 15 newsletters have been published. Alongside these regular publications, the third in a series of two year reports was published in 20142
. This biennial report provided an overview of radiotherapy error data reported as part of the national voluntary reporting scheme from December 2011 until November 2013. -8-
Clinical site visits provide further opportunities for dissemination of learning. These visits have developed in partnership with the clinical community and are informed through working with key stakeholders. Clinical site visits provide independent on-site support and reassurance on issues surrounding patient safety and process efficiency within the context of IR(ME)R. To date, 50 out of 77 departments across the UK have been visited, which affords an opportunity for shared learning. Previous feedback on the site visits from key stakeholders reported that clinical sites valued and benefited from an independent review of all aspects of the patient pathway, without the perceived threat of inspection. These visits allow the sharing of learning from the analysis of radiotherapy errors at a local level. The site visits consist of meetings and informal discussions with staff, providing opportunities to share best practice across departments. Learning from this work is also shared through national and international presentations, and PHE staff share learning when contributing to national meetings and national guidance.
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