Safety culture to improve accidental event reporting in radiotherapy

Abstract

Background and purpose. The potential for unintended and adverse radiation exposure in radiotherapy (RT) is real and should be studied because RT is a highly complex, multistep process, which requires input from numerous individuals from different areas and steps of the RT workflow. The ‘Incident’ (I) is an event the consequence of which is not negligible from the point of view of protection or safety. A ‘near miss’ (NM) is defined as an event that is highly likely to happen but did not occur. The purpose of this work is to show that through systematic reporting and analysis of these adverse events, their occurrence can be reduced. Materials and methods. Staff were trained to report every type of unintended and adverse radiation exposure and to provide a full description of it. Results. By 2018, 110 worksheets had been collected, with an average of 6.1 adverse events per year (with 780 patients treated per year, meaning an average incident rate of 0.78%). In 2001–2009, 37 events were registered (13 I and 24 NM), the majority of them were in the decision phase (12/37), while in 2010–2013, there were 42 (1 I and 41 NM) in both the dose-calculation and transfer phase (19/42). In 2014–2018, 31 events (1 I and 30 NM) were equally distributed across the phases of the RT process. In 9/15 cases of I, some checkpoint was introduced. Conclusion. The complexity of the RT workflow is prone to errors, and this must be taken into account by encouraging a safety culture. The aim of this paper is to present the collected incidents and near misses and to show how organization and practice were modified by the acquired knowledge.