Session: Improving Patient Safety in Radiotherapy
Global Safety Improvement Initiatives
Background
1. Starting point: Radiotherapy has significant global importance
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Ola Holmberg, PhD
An estimated 5.1 million courses of radiotherapy treatment were
administered annually between 1997 and 2007 (up from an estimated
4.3 million in 1988)*
• 50-60% of cancer patients could benefit from radiation therapy
• The fraction of cancer patients treated is increasing, where RT is available
Head, Radiation Protection of Patients Unit
Radiation Safety and Monitoring Section
NSRW
International Atomic Energy Agency - IAEA
Vienna, Austria
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International Atomic Energy Agency
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Background
* UNSCEAR 2008 Report
Background
2. Safety in radiotherapy is crucial
•
Over the last three decades, at least 3000 patients have been
affected by radiotherapy incidents and accidents
•
Radiation accidents involving medical uses have accounted for more
acute radiation deaths than any other source, including Chernobyl
•
These accidents do not only affect patients directly (e.g. harm and
death), but might also undermine the public’s confidence in the
treatment
•
Preventable medical errors overall also cost countries billions of
dollars each year
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Safety Improvement Initiatives
Safety Improvement Initiatives
Protection from risks
Protection from risks
City wall
Bastion
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Safety Improvement Initiatives
Safety Improvement Initiatives
Protection from risks
Adequate safety
infrastructure
Appropriate
staffing levels
Effective quality
assurance
Equipment
designed for safety
Educated and
trained staff
Direct safety
learning in RT
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Regional and inter-regional training courses in RT
•
Country projects in RT including scientific visits,
fellowships and national courses
•
Development of syllabi for training and education
of RT professionals
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Safety Improvement Initiatives
•
Development of recommendations for staffing
levels of radiation therapy centres
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New evidence-based guidance document being
developed for staffing based on procedures
done, not only patient numbers
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Development of standards on radiation safety and
assistance to Member States to implement these
standards
•
Development of guidance at different levels:
National, hospital, individual health professional
and also international calibration protocols
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Safety Improvement Initiatives
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Safety Improvement Initiatives
Safety Improvement Initiatives
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Postal TLD audits (IAEA/WHO network) to verify
the calibration of radiotherapy beams
•
Pushing for compliance with relevant International
Standards i.e. IEC/ISO or equivalent national
•
Comprehensive clinical audits (QUATRO)
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Planning and procurement of radiotherapy
equipment for developing countries
•
Guidance on Quality Control and commissioning
of equipment
•
Sponsoring the “Integrating the Healthcare
Enterprise in Radiation Oncology” (IHE-RO)
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Safety Improvement Initiatives
Why Safety Reporting and Learning?
France 2007 (1-year period)
•
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Dedicated website (rpop.iaea.org) for global
knowledge exchange on radiation protection of
patients (>10,000,000 hits per year)
•
Training material and books on radiotherapy safety
•
Safety reporting and learning system – SAFRON
(Safety in Radiation Oncology)
Why Safety Reporting and Learning?
France 2007 (1-year period)
USA 2009 (5-year period)
USA 2009 (5-year period)
From: W. Bogdanich, N.Y.Times, USA
From: S. Derreumaux, IRSN, France
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Why Safety Reporting and Learning?
France 2004
USA 2009?
From: W. Bogdanich, N.Y.Times, USA
From: S. Derreumaux, IRSN, France
From: S. Derreumaux, IRSN, France
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From: W. Bogdanich, N.Y.Times, USA
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Why Safety Reporting and Learning?
Why Safety Reporting and Learning?
Accidents and incidents still tend to “repeat themselves” – i.e. we need to
be better at learning from previous events
France 2004
USA 2009?
From: S. Derreumaux, IRSN, France
From: W. Bogdanich, N.Y.Times, USA
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SAFRON
Browse the process-steps to find safety information
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SAFRON
Safety information related to process step, from different sources
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SAFRON information-flow
Input
Output
Incident
reports
Other
systems
PSA
Local
info
SAFRON
Shared
info
Targeted
guidance
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SAFRON
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•
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•
Prototype ready
Next: run pilot with limited number of clinics
Next: populate system with historical data, events from collaborating systems,
prospective data etc., and continue to build links
Funding and manpower available
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Positive issues in relation to the system:
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IAEA has global reach
IAEA has well-established record in safety activities
IAEA is seen as independent
IAEA is well-placed to target guidance to all relevant stakeholders
Opportunity to place system on much visited web-site (rpop.iaea.org)
System developed in parallel with “radiological imaging system” SAFRAD
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Safety Improvement Initiatives
A good city wall with properly built bastions can be effective
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