Defining and Classifying Radiotherapy Errors

Summary Points

• After the Exeter incident, all RT centres had to implement QART.
• An error classification system should:-
• Define the terms used to avoid ambiguity.
• Provide a decision grid at an outcome-based classification for each event.
• Provide a detailed RT pathway coding system, which enables definition and coding of the point along the pathway at which the event occurred.
  

Definitions

• Radiotherapy (RT) error - a non-conformance where there is unintended divergence between a RT course delivered from local protocol.
• Radition Incident (RI) - a RT error where the radiation delivered is other than that which was intended.
• Correctable RI - can be compensated for so the radiobiological outcome remains the same.
• Reportable RI - this will be clinically significant. Or it may not be if it can be compensated for.
• Non-reportable RI - is of potential or actual clinical significance. Eg: 10% underdose over the course of a treatment due to a calculation error. Underdoses are NOT reportable under IRMER.
• Minor RI - an incident but of no potential or actual clinical significance.
• Near Miss - a potential radiation incident that was detected and prevented.
• Other Non-conformance - non-compliance with documented procedures not affecting the RT delivery.