Analysis and learning from radiotherapy and near miss data reported voluntarily by UK radiotherapy providers and the relevant reporting authorities.
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- United Kingdom
Table of Contents
- Full radiotherapy error data analysis 3 2
- Case study 6: Treatment data entry process 4 2
- August to November 2021 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 15 2
- Non-reportable radiation incident (Level 2) RTE 17 2
- Minor radiation incident (Level 3) RTE 18 2
- Near miss (Level 4) RTE 19 2
- Other non-conformance (Level 5) RTE 20 2
- Failed safety barriers 21 2
- Method of detection 22 2
- Causative factors 23 2
- Brachytherapy RTE 25 2
- References 28 2
- Full radiotherapy error data analysis 2
- Case study 6: Treatment data entry process 4
- Figure 1. Breakdown of inspectorate process subcodes from closed notifications (August to November 2021, n = 50/67 subset of data) 4
- Root causes or contributing factors 6
- Safety barriers 6
- Method of detection 6
- Corrective actions 6
- Learning from excellence and published guidance 6
- Table 1. Study of risk matrix 7
- August to November 2021 data analysis 8
- Number of RTE reports 8
- Monitoring of RTE coding by radiotherapy providers 8
- Figure 2. Breakdown of report completeness (n = 3,109) 10
- Number of reports per provider 11
- Figure 3. Number of RTE reported by provider (n = 3,099) 12
- Breakdown of process codes 12
- Figure 4. Breakdown of RTE process code by level (n = 2,956/3,099 subset of RTE) 13
- Figure 5. Breakdown of most frequently reported RTE process subcodes by level (n = 1,316/3,099 subset of RTE) 14
- Classification (level) of RTE 14
- Figure 6. Classification (level) of RTE reports (n = 3,099) 15
- Reportable radiation incident (Level 1) RTE 15
- Figure 7. Breakdown of level 1 RTE by process subcode (n = 35/47 subset of RTE) 16
- Non-reportable radiation incident (Level 2) RTE 17
- Figure 8. Breakdown of level 2 RTE by process subcode (n = 16/26 subset of RTE) 17
- Minor radiation incident (Level 3) RTE 18
- Figure 9. Breakdown of most frequently reported level 3 RTE by process subcode (n = 790/1,119 subset of RTE) 18
- Near miss (Level 4) RTE 19
- Figure 10. Breakdown of the most frequently reported level 4 RTE by process subcode (n = 370/814 subset of RTE) 20
- Other non-conformance (Level 5) RTE 20
- Figure 11. Breakdown of the most frequently reported level 5 RTE by process subcode (n = 418/1,093 subset of RTE) 21
- Failed safety barriers 21
- Figure 12. Breakdown of failed safety barriers by level (n = 1,516/2,188 subset of RTE data) 22
- Method of detection 22
- Figure 13. Breakdown of method of detection by level (n = 1,219/1,934 subset of RTE data) 23
- Causative factors 23
- Figure 14. Breakdown of most frequently reported RC by level (n = 2,961/3,099 subset of data) 24
- Figure 15. Breakdown of most frequently reported contributory factor (n = 857/902 subset of data) 25
- Brachytherapy RTE 25
- Figure 16. Breakdown of brachytherapy RTE coded ‘15’ by level (n = 17) 26
- Figure 17. Breakdown of brachytherapy failed safety barriers by level (n = 15) 27
- Figure 18. Breakdown of brachytherapy RTE root cause (n = 17) 27
- References 28
- About the UK Health Security Agency 29
