Cédric Guillaumon, Presenter: Nothing to Disclose

David Azria MD, PhD, Abstract Co-Author: Nothing to Disclose

Jean-Bernard Dubois MD, Abstract Co-Author: Nothing to Disclose

Norbert Ailleres PhD, Abstract Co-Author: Nothing to Disclose

Pascal Fenoglietto Dipl Phys, Abstract Co-Author: Nothing to Disclose

Purpose"Treatment safety is a constant concern for radiotherapy department. Recently, professional organizations, media and public were alerted by the occurrence of a wave of safety-related incidents. French health authorities subsequently called for a plan to improve safety and quality control in radiation therapy. Based on the Aeronautic industry methodology, our department implemented the Experience Feed back Committee (CREx) and risk mapping."Materials and Methods"CREx is made up of all groups of staff including radiation oncologists, physicists, team manager, dosimetrists, radiation therapists and nurses. The committee, who meet monthly, is dedicated to the registration, analysis, and correction of any reported precursor events.""The risk map focuses all relevant hazards potentially met throughout the radiation therapy process. All critical steps are identified, whereas apprehended events are ranked and scored according to their frequency and severity."Results"All incident data errors were thoroughly investigated and evaluated by the Crex. A total of 97 incident data were reported between the 1st of July 2008 and February 2010. Most of them (96%) were initially detected by therapists. The main dysfunctions were related to errors in patient’s identification, wrong block positioning, incomplete medical prescription, planning stage and treatment delivery without known adverse events. We could determine that 30% of events were caused by a lack of coordination between professionals. In response we elaborated detailed technical procedures, refined traceability and identity vigilance analysis. From now a continuing education program is intended to therapists and dosimetrists, including in-depth courses on treatment protocols and technical procedures, as well as medical knowledge updating. We also tend to homogenize medical practices in the department."Risk mapping mainly aimed to plan and target controls to be implemented to mitigate the risk. This quality process allowed developing suitable and efficient safety procedures in accordance with the revealed hazards.About 100 situations at risk were reported and preventive actions were organized.Conclusion"The implementation of the CREx and risk mapping involved an optimal management of quality based on the development of both preventive and corrective actions. Thanks to a multidisciplinary approach, we significantly reduced the number of events, and improved the organizational culture and practices in our department. According to national requirements we are fully committed to enforce and correct treatment performance to strengthen the radiation oncology safety."

Guillaumon, C, Azria, D, Dubois, J, Ailleres, N, Fenoglietto, P, Feedback Experience and Risk Mapping: Two Efficient Tools to Optimize Quality Management and Reduce Risk in Radiotherapy.  Radiological Society of North America 2010 Scientific Assembly and Annual Meeting, November 28 - December 3, 2010 ,Chicago IL. http://archive.rsna.org/2010/9020147.html