Sécurité en radiothérapie : résultats de trois ans d’expérience avec la Mission nationale d’expertise et d’audits hospitalier (MEAH)

[The morbidity and mortality review meetings in radiotherapy departments: Procedure, implementation and prospects of the "Proust" French national project]

Radiation-induced acute and late toxicity depends on several parameters. The type, severity and duration of morbidity are mainly related to irradiated volume, total dose and its fractionation and the intrinsic radiosensitivity of the patients. The follow-up of these toxicities is essential. However, unlike many specialties, morbidity and mortality reviews procedures are not developed as part of quality governance programs in radiation therapy departments for the monitoring of toxicity which sometimes hinder the patients' quality of life. One French survey published within the framework of the project entitled Prospective Registration of Morbidity and Mortality, Individual Radiosensitivity and Radiation Technique (Proust), conclude that there was a lack of knowledge of morbidity and mortality reviews and considerable confusion between these reviews and other quality processes without perspective for the local morbidity and mortality reviews development in a large number of the participated centers. In this article, we will discuss the procedure of the "ideal morbidity and mortality reviews" and its implementation through a monocentric experience started in 2015. Thus, the Proust project is a unique opportunity to implement and standardize a national morbidity and mortality reviews implementation in radiation therapy departments by involving the French regions.

[Risk analysis in radiation therapy: state of the art]

Five radiotherapy accidents, from which two serial, occurred in France from 2003 to 2007, led the authorities to establish a roadmap for securing radiotherapy. By analogy with industrial processes, a technical decision form the French Nuclear Safety Authority in 2008 requires radiotherapy professionals to conduct analyzes of risks to patients. The process of risk analysis had been tested in three pilot centers, before the occurrence of accidents, with the creation of cells feedback. The regulation now requires all radiotherapy services to have similar structures to collect precursor events, incidents and accidents, to perform analyzes following rigorous methods and to initiate corrective actions. At the same time, it is also required to conduct analyzes a priori, less intuitive, and usually require the help of a quality engineer, with the aim of reducing risk. The progressive implementation of these devices is part of an overall policy to improve the quality of radiotherapy. Since 2007, no radiotherapy accident was reported.

[Functional modeling for risk analysis in radiotherapy]

PURPOSE

This document presents a systematic and structured approach for functional modeling for risk analysis in radiotherapy, aiming to reconcile the need, on one hand, for a method that can be applied generally and, on the other hand, for a method that provides a highly precise model.

MATERIALS AND METHODS

The approach relies on new functional structuring patterns and flux analysis, derived from system engineering and knowledge engineering.

RESULTS

The method affords strong support for the development of detailed models of the patient's process through a department of radiotherapy. Lack of structure of the actual process in a particular department may be easily identified leading to the development of specific procedures for the improvement of security.

CONCLUSION

Modeling approach derived from engineering may be used for functional modeling for risk analysis in radiotherapy.

[FMEA applied to the radiotherapy patient care process]

PURPOSE

Failure modes and effects analysis (FMEA), is a risk analysis method used at the Radiotherapy Department of Institute Sainte-Catherine as part of a strategy seeking to continuously improve the quality and security of treatments.

PATIENTS AND METHODS

The method comprises several steps: definition of main processes; for each of them, description for every step of prescription, treatment preparation, treatment application; identification of the possible risks, their consequences, their origins; research of existing safety elements which may avoid these risks; grading of risks to assign a criticality score resulting in a numerical organisation of the risks. Finally, the impact of proposed corrective actions was then estimated by a new grading round.

RESULTS

For each process studied, a detailed map of the risks was obtained, facilitating the identification of priority actions to be undertaken. For example, we obtain five steps in patient treatment planning with an unacceptable level of risk, 62 a level of moderate risk and 31 an acceptable level of risk.

CONCLUSION

The FMEA method, used in the industrial domain and applied here to health care, is an effective tool for the management of risks in patient care. However, the time and training requirements necessary to implement this method should not be underestimated.