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

[Ethical stakes of information in radiation oncology: Thinking the risk and building the therapeutic alliance]

Informing patients before receiving radiation therapy is a fundamental ethical imperative. As a condition of the possibility of autonomy, information allows people to make health decisions concerning themselves, which is required by French law. This information includes in particular the potential risks due to radiation therapy. It is therefore necessary to think about what risk is, and how to define and assess it, in order to finally communicate it. The practice of informing people involves many ethical issues relating to the very content of the information, the form in which it is transmitted or even the intention that leads the health professional to say (or not to say) the risk. The transmission of information also questions the way to build a relationship of trust with the patients and how to integrate their own representations about these treatments. Between the risks of paternalism or even defensive medicine, this practice is at the heart of our professional practice.

[Radiation TherapisTs Radiographer (RTTs) and risk management in radiotherapy: An international survey]

PURPOSE

In order to study the role perception and the effective involvement of Radiation TherapisTs (RTTs) in risk management in radiotherapy, a survey was developed and distributed in five countries (France, Switzerland, Belgium, Ireland, the Netherlands).

MATERIALS AND METHODS

The article presents the results of this survey and the comparison between the different countries.

RESULTS

Overall, the results of the survey show a good involvement and perception of the RTTs around the risk management approach, although training in this area has yet to be systematized.

CONCLUSION

Although with differences in the results between the participating countries, the survey seems to highlight the deployment of preventive actions that are evaluated as not very effective by the respondents and by the international scientific literature.

Patient safety in external beam radiotherapy, results of the ACCIRAD project: Current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe

PURPOSE

To describe the current status of implementation of European directives for risk management in radiotherapy and to assess variability in risk management in the following areas: 1) in-country regulatory framework; 2) proactive risk assessment; (3) reactive analysis of events; and (4) reporting and learning systems.

MATERIAL AND METHODS

The original data were collected as part of the ACCIRAD project through two online surveys.

RESULTS

Risk assessment criteria are closely associated with quality assurance programs. Only 9/32 responding countries (28%) with national regulations reported clear "requirements" for proactive risk assessment and/or reactive risk analysis, with wide variability in assessment methods. Reporting of adverse error events is mandatory in most (70%) but not all surveyed countries.

CONCLUSIONS

Most European countries have taken steps to implement European directives designed to reduce the probability and magnitude of accidents in radiotherapy. Variability between countries is substantial in terms of legal frameworks, tools used to conduct proactive risk assessment and reactive analysis of events, and in the reporting and learning systems utilized. These findings underscore the need for greater harmonisation in common terminology, classification and reporting practices across Europe to improve patient safety and to enable more reliable inter-country comparisons.

[Practical risk analysis]

Risk analysis is typically considered from two complementary points of view: predictive analysis performed prior, and retrospective analysis, which follows the internal reporting of adverse situations or malfunctions, both on the organizational and material or human aspects. The purpose of these additional analyzes is to ensure that planned or implemented measures allow to keep risks to a level deemed tolerable or acceptable at a given time and in a given situation. Where a risk is deemed unacceptable, risk reduction measures should be considered (prevention, limiting the consequences and protection).

Implementation of the global risk analysis in pulsed-dose rate brachytherapy: methods and results

PURPOSE

To report the application of the global risk analysis (GRA) in the pulsed-dose rate (PDR) brachytherapy workflow.

MATERIAL AND METHODS

Analyses were led by a multidisciplinary working group established within the unit with the guidance of a quality engineer. First, a mapping of hazardous situations was developed as a result of interactions between the patient workflow for a treatment using PDR brachytherapy split into 51 sub-phases with a comprehensive list of the hazards that he/she faces (44). Interactions, when relevant, were sorted by level of priority: to be treated immediately, secondarily (the group is not entitled to treat the situation), or later (safe situation). Secondly, for each high priority dangerous situation, scenarios were developed to anticipate their potential consequences. Criticality was assessed, using likelihood and severity scales and a matrix, which allocated risks into categories: acceptable (C1), tolerable under control (C2) and unacceptable (C3). Then, corrective actions were proposed and planned when relevant, after assessment of their feasibility with a scale of effort. Finally, the criticality of the scenarios was reevaluated, taking into account the implementation of these actions, leading to a residual risk mapping, which could trigger additional proposals of actions.

RESULTS

Two thousand one hundred and eighty-four potential interactions between the list of hazards and the workflow were analyzed. Mapping of dangerous situations identified 213 relevant interactions, from which 61 were considered with high priority. One hundred and twenty-six scenarios were generated: 68 with a low criticality (74.3%), 58 with an intermediate score (25.7%). No scenario with the highest criticality was individualized. Twenty-one corrective actions were planned. Mapping of residual risk resulted in the disappearance of most C2 risks, leaving 5 C2 scenarios (4%), for which four monitoring indicators were implemented in addition to the corrected actions decided on.

CONCLUSION

The implementation of the GRA appeared feasible, and led to implement 21 corrective actions, based on scenarios and not on incidents.