Guidance

Radiotherapy: learning from errors

Supplementary guidance to support the radiotherapy community.

Documents

Radiotherapy error and near miss reporting: the unseen pathway

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Development of learning from radiotherapy errors: supplementary guidance

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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. Added 'Radiotherapy error and near miss' report.

  2. First published.