Patient incidents in radiotherapy

Question 1

Who may need to be notified following an incident?

Answer 1

• Patient or patient representative (required by IR(ME)R if clinically significant).
• Patient’s referrer and practitioner (oncologist).
• Others involved with the exposure (e.g. head of service, MPE, lead radiographer, manager, RPA, risk department etc.).

Question 1

What should be considered initially for a radiotherapy patient incident investigation?

Answer 1

• What happened?
• Has the patient been under-/over-exposed?
• Is the incident relating to a single fraction or many fractions?
• Was there an equipment fault?
• Is the incident correctable? i.e. should treatment be stopped, paused, continued, modified etc.?

Question 2

What needs to be considered at the end of a radiotherapy treatment course during which there was a non-notifiable incident for a single fraction and treatment was continued?

Answer 2

• Has the original intention been achieved?
• Is the final dose such that it now triggers notification?
• Was the impact of the incident clinically significant for the patient?

Question 3

When should an investigation begin after an incident? What might this involve? When should the CQC be notified?

Answer 3

• Immediate preliminary investigation should be undertaken.
• Ascertaining who was involved and collecting their recollections of events. Identifying root cause. Identifying learning/actions required.
• If a SAUE is not ruled out, an immediate notification to CQC should be made.