This Article Full Text Full Text (PDF) Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Williams, M V Search for Related Content PubMed PubMed Citation Articles by Williams, M V

Improving patient safety in radiotherapy by learning from near misses, incidents and errors

Faculty of Clinical Oncology, The Royal College of Radiologists, 38 Portland Place, London W1B 1JQ, UK

Correspondence: Dr Michael Williams, Faculty of Clinical Oncology, The Royal College of Radiologists, 38 Portland Place, London W1B 1JQ, UK. E-mail: michael-williams{at}rcr.ac.nhs.uk

Radiotherapy incidents involving a major overdose such as that which affected a patient in Glasgow in 2006 are rare. The publicity surrounding this patient's treatment and the subsequent publication of the enquiry by the Scottish Executive have led to a re-evaluation of procedures in many departments. However, other incidents and near misses that might also generate learning are often surrounded by obsessive secrecy. With the passage of time, even those incidents that have been subject to a public enquiry are lost from view. Indeed, the report on the incident in Glasgow draws attention to strong parallels with that in North Staffordshire, the report of which is not freely available despite being in the public domain. A web-based system to archive and make available previously published reports should be relatively simple to establish. A greater challenge is to achieve open reporting of near misses, incidents and errors. The key elements would be the effective use of keywords, a system of classification and a searchable anonymized database with free access. There should be a well designed system for analysis, response and feedback. This would ensure the dissemination of learning. The development of a more open culture for reports under the Ionising Radiation (Medical Exposure) Regulations (IR(ME)R) is essential: at the very least, their main findings and recommendations should be routinely published. These changes should help us to achieve greater safety for our patients.

This article has been cited by other articles:

				BJR review of the year -- 2007 Br. J. Radiol., April 1, 2008; 81(964): 265 - 269. [Full Text] [PDF]