Guidance

Radiotherapy: learning from errors

Supplementary guidance to support the radiotherapy community.

• From: Public Health England
• Published: 22 December 2016
• Last updated: 11 May 2021 — See all updates

Documents

Radiotherapy error and near miss reporting: the unseen pathway

Ref: PHE publications gateway number: GOV-7991

PDF, 1.21 MB, 36 pages

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Development of learning from radiotherapy errors: supplementary guidance

Ref: PHE publications gateway number: 2016522

PDF, 294 KB, 38 pages

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Details

This analysis of radiotherapy errors, carried out by Public Health England (PHE), has been reviewed by the Patient Safety in Radiotherapy Steering Group and the Institute of Physics and Engineering in Medicine, Radiotherapy Specialist Interest Group, whose comments have been incorporated.

The analysis encourages reporting and learning from radiotherapy error and near misses (RTE), contains trend analysis and shared learning from RTE of the unseen pathway, and presents 5 case studies which include a study of risk, mitigations and learning from excellence.

The supplementary guidance presents a refinement of the radiotherapy pathway coding, which includes the introduction of the safety barrier taxonomy, a new causative factor taxonomy, and provides guidance on the application of these taxonomies.

The guidance shares submission procedures for coding with radiotherapy staff and risk managers for inclusion in the national analysis.

Published 22 December 2016
Last updated 11 May 2021 + show all updates

1. 11 May 2021

   Added 'Radiotherapy error and near miss' report.

2. 22 December 2016

   First published.