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Voluntary reporting of errors in radiotherapy. Errors collection in radiotherapy


Abstract


A reporting worksheet was developed in 2001 to collect the errors discovered in the department. The worksheet comprised the following variables: body site, machine and energy, phase of RT procedure, description of incident, how discovered, date of incident, date of discovery, staff member involved in incident and staff member who discovered it (only qualification). The personnel was required reporting events explaining the importance of safeguarding patients and assuring that no disciplinary trial would be opened. Up to 2016 were collected 101 worksheets. 34 in breast treatments, 21 Head and Neck (H&N), 9 Chest, 19 Pelvis, 13 bone metastases (MTX), 5 brain. In 2001-2009 were collected 37 events, 24 Near Miss (NM), 13 Incident (I), 2 of them harmful. In 2009-2012 42 NM, no I, 2014-2016 22 events, 21 NM and 1 incident. In 2001-2009 majority of the errors was made in prescription phase (12/37), in 2009-2012 in dose-calculation phase and transfer phase (19/42). In 2014-2016 the events were balanced in all the phases. Although voluntary reporting of errors does not discover all the errors, it permits to improve the procedures and to increase a positive culture towards errors. Their distribution among sites of treatment, professionals and steps of the treatment pathways is significant different in the three periods considered. Collection and analysis of errors may improve patient's safety in radiation oncology.

DOI Code: 10.1285/i9788883051555p84

Keywords: Radiotherapy risk management; reporting; patient safety

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