Seguridad en radioterapia. Resultados tras 9años de la implementación de un registro de incidentes

INTRODUCTION: Radiation therapy (RT) is a complex process that employs high-dose radiation for therapeutic purposes. Incident reporting and analysis, in addition to being a legal requirement in RT, provides information that helps to improve patient safety. This paper describes our experiences over a 9 year period in which a local incident reporting and learning system (SNAI) specific to RT was employed.
MATERIALS AND METHODS: The center has 4 lineal accelerators that treat a total of 1900 patients annually. The first action taken with a view to improving patient safety was the implementation of a multidisciplinary RT safety group (GSRT), who decided to employing a methodology based on incident reporting. For this purpose, a local SNAI was implemented, adapting the ROSEIS incident reporting system used and consolidated by the European Society of Radiation Oncology Therapy (ESTRO). All incidents in which patients received an incorrect RT session were considered adverse events (AE) and were thus analyzed. Finally, the opinion of the professionals involved in relation to the SNAI and the functioning of the safety group was evaluated by means of a survey.
RESULTS: From June 2009 to October 2018, 1708 incidents were recorded, with an increasing incidence observed over time. Approximately 2.5% of the incidents reported were AE. The remainders were events that did not affect the patient. As many as 55% of incidents were detected in the treatment administration phase. Radiotherapy technicians were the professionals who reported more incidents. The majority of recorded cases originated from procedural shortcomings relating to communication or work protocols. Implemented remedial actions were aimed at reducing the frequency of AE and facilitating its early detection. Actions employed were essentially: drafting and revision of protocols and circuits, implementation of checklists, and training actions. Of the workers surveyed, 85% positively valued the incorporation of the SNAI and the existence of a safety group. However, 15% of the professionals considered that the methodology used in the analysis of incidents was not totally objective i.e punitive in nature.
CONCLUSIONS: The safety of the patient receiving RT has been approached from a methodology based on a local SNAI. The analysis of reported incidents has promoted various actions aimed at improving the safety of patients receiving RT. The methodology used has been well received by the workers and has helped to introduce a culture of patient safety for the majority of professionals involved. Furthermore, the local SNAI facilitates compliance with European regulations regarding the obligation to record incidents in RT.