Skip to main content
Top
Published in: Clinical and Translational Oncology 5/2020

01-05-2020 | Radiotherapy | Research Article

Patient safety in radiation oncology in Spain: a need to change

Authors: J. Pardo Masferrer, E. del Cerro Peñalver, J. Contreras Martinez, C. Ferrer Albiach, On behalf of the Patient Safety and Quality Working Group of the Spanish Society of Radiation Oncology (SEOR)

Published in: Clinical and Translational Oncology | Issue 5/2020

Login to get access

Abstract

Purpose

The Working Group on Patient Safety and Quality of the Spanish Society of Radiation Oncology, revised the most relevant national and international recommendations, selecting a series of important aspects for patient safety, evaluating whether they are included in Spanish legislation

Materials and methods

We have considered a concept as relevant to the patient safety in radiotherapy if so defined in at least 8 of the 16 documents reviewed.

Results

12 subjects were selected: training and qualification, human resources, protocols, safety culture, communication, peer review, accreditation: audits, checklists, areas without interruptions, maps of processes and risks, prospective risk analysis, notification, registration and incident learning, and quality control of the equipment.

Conclusions

At the legislative level, as well as the professional organizations and the health center directorates, the implementation of safety culture must continue to be fostered. Only in this environment will the tools and measures to increase patient safety be effective. The current Spanish legislation must be revised and updated, in accordance with directive 2013/59/EURATOM and the Patient Safety Strategy 2015–2020 of the Spanish National Health System, introducing the obligation to perform risk analysis and incidents management. Audits and accreditations must be carried out, thus raising the general level of practice of the specialty. In this process, the Spanish Society of Radiation Oncology must continue playing its fundamental role, collaborating with the institutions and the rest of the scientific societies involved in the radiotherapy process, issuing recommendations on patient safety and disseminating the safety culture in our specialty.
Literature
1.
go back to reference Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. The IOM committee’s first report. Institute of Medicine (US) Committee on Quality of Health Care in America; National Academies Press (US); 2000. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. The IOM committee’s first report. Institute of Medicine (US) Committee on Quality of Health Care in America; National Academies Press (US); 2000.
2.
go back to reference Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.CrossRef Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016;353:i2139.CrossRef
3.
go back to reference Real Decreto 1566/1998, de 17 de julio, por el que se establecen los criterios de calidad en radioterapia. BOE núm. 206, de 28 de agosto de 1998, páginas 29383 a 29394. Real Decreto 1566/1998, de 17 de julio, por el que se establecen los criterios de calidad en radioterapia. BOE núm. 206, de 28 de agosto de 1998, páginas 29383 a 29394.
4.
go back to reference Real Decreto 815/2001, de 13 de julio, sobre justificación del uso de las radiaciones ionizantes para la protección radiológica de las personas con ocasión de exposiciones médicas. BOE 168, de 14 de Julio de 2001, páginas 25591 a 25594. Real Decreto 815/2001, de 13 de julio, sobre justificación del uso de las radiaciones ionizantes para la protección radiológica de las personas con ocasión de exposiciones médicas. BOE 168, de 14 de Julio de 2001, páginas 25591 a 25594.
5.
go back to reference Duscombe P. Recommendations for safer radiotherapy: what’s the message? Front Oncol. 2012;2, article 129. Duscombe P. Recommendations for safer radiotherapy: what’s the message? Front Oncol. 2012;2, article 129.
8.
go back to reference Rath F. Tools for developing a quality management program: proactive tools (process mapping, value stream mapping, fault tree analysis, and failure model and effects analysis). Int J Radiat Oncol Biol Phys. 2008;71:s187–90.CrossRef Rath F. Tools for developing a quality management program: proactive tools (process mapping, value stream mapping, fault tree analysis, and failure model and effects analysis). Int J Radiat Oncol Biol Phys. 2008;71:s187–90.CrossRef
9.
go back to reference Huq MS, Fraass BA, Dunscombe PB, Gibbons JP Jr, Ibbott GS, Medin PM, Mundt A, Mutic S, Palta JR, Thomadsen BR, Williamson JF, Yorke ED. A method for evaluating assurance needs in radiation therapy. Int J Radiat Oncol Biol Phys. 2008;71:s170–3.CrossRef Huq MS, Fraass BA, Dunscombe PB, Gibbons JP Jr, Ibbott GS, Medin PM, Mundt A, Mutic S, Palta JR, Thomadsen BR, Williamson JF, Yorke ED. A method for evaluating assurance needs in radiation therapy. Int J Radiat Oncol Biol Phys. 2008;71:s170–3.CrossRef
10.
go back to reference Ford EC, Gaudette R, Myers L, Vanderver B, Engineer L, Zellars R, Song J, DeWeese DY. Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. Int J Radiat Oncol Biol Phys. 2009;74(3):852–8.CrossRef Ford EC, Gaudette R, Myers L, Vanderver B, Engineer L, Zellars R, Song J, DeWeese DY. Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. Int J Radiat Oncol Biol Phys. 2009;74(3):852–8.CrossRef
11.
go back to reference Aplicación del método de la matriz de riesgo a la Radioterapia. OIEA. VIENA 2012. IAEA-TECDOC-1685/S. ISBN 978-92-0-332510-3. ISSN 1011-4289. Aplicación del método de la matriz de riesgo a la Radioterapia. OIEA. VIENA 2012. IAEA-TECDOC-1685/S. ISBN 978-92-0-332510-3. ISSN 1011-4289.
12.
go back to reference International Commission of Radiological Protection. preventing accidental exposures from new external beam radiation therapy technologies. Ann ICRP. 2009;39:1–2. International Commission of Radiological Protection. preventing accidental exposures from new external beam radiation therapy technologies. Ann ICRP. 2009;39:1–2.
13.
go back to reference Bogdanich W. The radiation boom. Radiation offers new cures and ways to do harm. N Y Times. 2010. Bogdanich W. The radiation boom. Radiation offers new cures and ways to do harm. N Y Times. 2010.
17.
go back to reference Council Directive 2013/59/EURATOM of 5 December 2013, laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Official Journal of the European Union. 2014. Council Directive 2013/59/EURATOM of 5 December 2013, laying down basic safety standards for protection against the dangers arising from exposure to ionising radiation, and repealing Directives 89/618/Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and 2003/122/Euratom. Official Journal of the European Union. 2014.
18.
go back to reference Duscombe P, Grau C, Defourny N, Malicki J, Borras JM, Coffey M, et al. Guidelines for equipment and staffing of radiotherapy facilities in the European countries: Final results of the ESTRO-HERO survey. Radiother Oncol. 2014;112:165–77.CrossRef Duscombe P, Grau C, Defourny N, Malicki J, Borras JM, Coffey M, et al. Guidelines for equipment and staffing of radiotherapy facilities in the European countries: Final results of the ESTRO-HERO survey. Radiother Oncol. 2014;112:165–77.CrossRef
22.
go back to reference Malicki J, Bly R, Bulot M, Godet JL, Jahnen A, Krengli M, Maingon P, Prieto Martin C, Przybylska K, Skrobała A, Valero M, Jarvinen H. 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. Radiother Oncol. 2017;123(1):29–36. https://doi.org/10.1016/j.radonc.2017.02.016(epub 2017 Mar 25).CrossRefPubMed Malicki J, Bly R, Bulot M, Godet JL, Jahnen A, Krengli M, Maingon P, Prieto Martin C, Przybylska K, Skrobała A, Valero M, Jarvinen H. 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. Radiother Oncol. 2017;123(1):29–36. https://​doi.​org/​10.​1016/​j.​radonc.​2017.​02.​016(epub 2017 Mar 25).CrossRefPubMed
23.
go back to reference Malicki J, Bly R, Bulot M, Godet JL, Jahnen A, Krengli M, Maingon P, Prieto Martin C, Przybylska K, Skrobała A, Valero M, Jarvinen H. Patient safety in external beam radiotherapy, results of the ACCIRAD project: recommendations for radiotherapy institutions and national authorities on assessing risks and analyzing adverse error-events and near misses. Radiother Oncol. 2018;127:164–70. https://doi.org/10.1016/j.radonc.2018.04.006(epub 2018 May 2).CrossRefPubMed Malicki J, Bly R, Bulot M, Godet JL, Jahnen A, Krengli M, Maingon P, Prieto Martin C, Przybylska K, Skrobała A, Valero M, Jarvinen H. Patient safety in external beam radiotherapy, results of the ACCIRAD project: recommendations for radiotherapy institutions and national authorities on assessing risks and analyzing adverse error-events and near misses. Radiother Oncol. 2018;127:164–70. https://​doi.​org/​10.​1016/​j.​radonc.​2018.​04.​006(epub 2018 May 2).CrossRefPubMed
Metadata
Title
Patient safety in radiation oncology in Spain: a need to change
Authors
J. Pardo Masferrer
E. del Cerro Peñalver
J. Contreras Martinez
C. Ferrer Albiach
On behalf of the Patient Safety and Quality Working Group of the Spanish Society of Radiation Oncology (SEOR)
Publication date
01-05-2020
Publisher
Springer International Publishing
Keyword
Radiotherapy
Published in
Clinical and Translational Oncology / Issue 5/2020
Print ISSN: 1699-048X
Electronic ISSN: 1699-3055
DOI
https://doi.org/10.1007/s12094-019-02184-x

Other articles of this Issue 5/2020

Clinical and Translational Oncology 5/2020 Go to the issue
Webinar | 19-02-2024 | 17:30 (CET)

Keynote webinar | Spotlight on antibody–drug conjugates in cancer

Antibody–drug conjugates (ADCs) are novel agents that have shown promise across multiple tumor types. Explore the current landscape of ADCs in breast and lung cancer with our experts, and gain insights into the mechanism of action, key clinical trials data, existing challenges, and future directions.

Dr. Véronique Diéras
Prof. Fabrice Barlesi
Developed by: Springer Medicine