Safer radiotherapy: triannual error analysis and learning: Safer RT: triannual error analysis and learning report, issue 37

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Table of Contents

• Full radiotherapy error data analysis 3 2
• Inspectorate data 4 2
• Case study 7: Brachytherapy, initial positioning of applicator or sources 4 2
• December 2021 to March 2022 data analysis 8 2
• Number of RTE reports 8 2
• Monitoring of RTE coding by radiotherapy providers 8 2
• Number of reports per provider 11 2
• Breakdown of process codes 12 2
• Classification (level) of RTE 14 2
• Reportable radiation incident (Level 1) RTE 14 2
• Non-reportable radiation incident (Level 2) RTE 16 2
• Minor radiation incident (Level 3) RTE 17 2
• Near miss (Level 4) RTE 18 2
• Other non-conformance (Level 5) RTE 19 2
• Failed safety barriers 21 2
• Method of detection 22 2
• Causative factors 23 2
• Brachytherapy RTE 24 2
• References 27 2
• About the UK Health Security Agency 29 2
• Full radiotherapy error data analysis 2
• Inspectorate data 4
• Figure 1. Breakdown of most frequently reported inspectorate process subcodes from closed notifications (n = 46/66 subset of data) 4
• Case study 7: Brachytherapy, initial positioning of applicator or sources 4
• Synopsis 5
• Causative factors 5
• Safety barriers 5
• Method of detection 6
• Corrective actions 6
• Learning from excellence and published guidance 6
• Table 1. Study of risk matrix 7
• December 2021 to March 2022 data analysis 8
• Number of RTE reports 8
• Monitoring of RTE coding by radiotherapy providers 8
• Figure 2. Breakdown of report completeness (n = 3,312) 10
• Number of reports per provider 11
• Figure 3. Number of RTE reported by provider (n = 3,289) 11
• Breakdown of process codes 12
• Figure 4. Breakdown of RTE process code by level (n = 3,140/3,289 subset of RTE) 12
• Figure 5. Breakdown of most frequently reported RTE process subcodes by level (n = 1,412/3,289 subset of RTE) 13
• Classification (level) of RTE 14
• Figure 6. Classification (level) of RTE reports (n = 3,289) 14
• Reportable radiation incident (Level 1) RTE 14
• Figure 7. Breakdown of most frequently reported level 1 RTE by process subcode (n = 31/43 subset of RTE) 15
• Non-reportable radiation incident (Level 2) RTE 16
• Figure 8. Breakdown of most frequently reported level 2 RTE by process subcode (n = 21/12 subset of RTE) 16
• Minor radiation incident (Level 3) RTE 17
• Figure 9. Breakdown of most frequently reported level 3 RTE by process subcode (n = 846/1,175 subset of RTE) 17
• Near miss (Level 4) RTE 18
• Figure 10. Breakdown of most frequently reported level 4 RTE by process subcode (n = 422/908 subset of RTE) 19
• Other non-conformance (Level 5) RTE 19
• Figure 11. Breakdown of most frequently reported level 5 RTE by process subcode (n = 506/1,142 subset of RTE) 20
• Failed safety barriers 21
• Figure 12. Breakdown of failed safety barriers (n = 1,469/2,196 subset of RTE data) 21
• Method of detection 22
• Figure 13. Breakdown of method of detection by level (n = 1,244/1,972 subset of RTE data) 22
• Causative factors 23
• Figure 14. Breakdown of most frequently reported CF (n = 4,055/4,240 subset of data) 23
• Brachytherapy RTE 24
• Figure 15. Breakdown of most frequently reported brachytherapy RTE coded ‘15’ by level (n = 23/29 subset of data) 24
• Figure 16. Breakdown of brachytherapy failed safety barriers (n = 14) 25
• Figure 17. Breakdown of brachytherapy RTE CF (n = 28/33 subset of RTE) 26
• References 27
• About the UK Health Security Agency 29