Incidents Flashcards
Who must incidents be reported to?
CQC
Care Quality Commission
Where is guidance for criteria for making a notification?
Provided by CQC, notification codes
Radiotherapy board has given more in IRMER Implications
What is reportable with respect to RT treatments?
An overdose of 1.1x intended dose over entire treatment
An overdose of 1.2x intended dose at one fraction
An underdose of 0.9x intended dose over entire treatment
What is reportable with respect to RT planning scans?
If planning scan must be repeated twice (3 scans in total)
What is reportable with respect to RT verification images?
Set up errors leading to 3 or more imaging exposures in one fraction
When number of additional exposures is 50% greater than intended over treatment due to protocol failure
When number of additional imaging exposures is 50% greater than intended over treatment due to thematic hardware or software failure
What is reportable with respect to geographical misses?
All total geographical misses, even for one fraction or a part of one
Partial miss where the miss exceeds 2.5 times the locally defined error margin and the guideline dose factors for the PTV or OAR are exceeded
What are the levels of RT error and what do they mean has happened?
1: reportable RI
2: non-reportable RI (not reportable but clinically significant or could be)
3: minor RI (correctable or not clinically significant RI)
4: near miss (potential RI was detected and prevented)
5: other non-conformance (non-compliance with some aspect of procedure but not affecting treatment)
What is a RT error?
A non-conformance where there is an unintended divergence between a RT treatment delivered or RT process followed and that defined as correct by local protocol.
(can lead to RI, but not all errors lead to incidents)
What is an RT incident?
An RT error where the delivery of radiation during a course of RT differs to that which was intended by the prescribing practitioner as defined in IRMER and which could have resulted in, or did result in, patient harm
What is a correctable RI?
An RI that can be compensated for such that radiobiologically the final outcome is not different in terms of clinical significance from that which was intended.
What would you do in the event of detecting an incident?
Do preliminary investigation. If beyond reasonable doubt, it should be reported.
Inform an MPE
Decide what to do about the patient: inform a clinician and come to a conclusion, should the treatment stop or can it be altered to account for incident
Report to CQC if SAUE (within no more than 2 weeks)
Do thorough investigation
Submit report of investigation within 12 weeks
Look at lessons learned, implement changes
Inform patient, apologise etc
Non-reportable incidents should still be investigated and analysed locally
What is an accidental exposure?
One where the patient was not expected to receive any radiation dose at all, but does receive a dose
What is an unintended exposure?
One where the patient was expected to receive an exposure, but the exposure differs to that planned.
What does SAUE stand for
Significant accidental or unintended exposures
Where defines accidental and unintended exposure?
IRMER
