Patient Incidents in RT

Question 1

When is an incident reportable to the HSE?

Answer 1

When the incident is due to equipment malfunction or failure.
This is applicable to both imaging and therapeutic equipment.

It is also reported to the MHRA.

Question 2

What is the MGTI multiplication factor for a whole course of treatment?

Answer 2

1.1

Question 3

What is the MGTI multiplication factor for a single fraction?

Answer 3

1.2

Question 4

Is an underdose reportable?

Answer 4

No

Question 5

What is the MGTI multiplication factor for CT imaging?

Answer 5

1.5

Question 6

What is the MGTI multiplication factor for planar imaging?

Answer 6

20

Question 7

When is an incident reportable to the CQC?

Answer 7

If it is not due to equipment malfunction, i.e: a procedural fail.

Question 8

When is a repeated exposure justified?

Answer 8

Only if the exposure if terminated prior to reaching the MGTI limit and is due to equipment fault.
If over MGTI, still justified but HSE should be informed.

Question 9

What literature is a good practice guide on all aspects of ionising radiation protection in a clinical environment?

Answer 9

Medical and Dental Guidance Notes, published by IPEM.

Question 10

What is the purpose of TSR?

Answer 10

Towards Safer Radiotherapy was produced to reduce errors.
It introduced a classification system for non-equipment caused errors.
It allows national sharing of similar incidents to allow trends to be seen. Therefore, it shows the most riskt part of RT process.

Question 11

What are the levels of TSR RT errors?

Answer 11

Level 1: Reportable incident (Radiation incident & reportable)

Level 2: Non-reportable incident (Radiation incident, not reportable, uncorrectable, and clinically significant)

Level 3: Minor radiation incident (Radiation incident, not reportable, either correctable or clinically insignificant)

Level 4: Near miss (Not radiation incident, but potential for one)

Level 5: Other non-conformance (Not radiation incident, and no potential for one)

Question 12

What information is desired to investigate a potential radiation incident?

Answer 12

• What happened
• Has the patient been over-dosed?
• One fraction or many?
• Is the incident correctable?
• Is it an equipment fault – does it need to be taken out of use?
• What should happen to the patient now?:
  
  • Stop?
  • Stop until we can calculate what to do?
  • Continue as current?
  • Continue as originally intended
  • Continue with modified dose?

Question 13

Name 3 local persons who may need to be notified of a radiation incident.

Answer 13

Patient if appropriate under policy & duty of candour 
Clinical director
Radiotherapy Head of Service
Patient’s oncologist
Head of radiotherapy physics
Lead radiographer
Directorate manager
Physics service lead
RPA if appropriate
Risk department
Hosp incident DB
Trust Exec?
SHA?

Question 14

Where are lost sources reported to?

Answer 14

The environment agency.

Question 15

What corrective actions may be considered after an incident?

Answer 15

• Review and Clarification of procedure
• Training
• New procedure
• Disciplinary action