ESTRO 2024 - Abstract Book

S5909

RTT - Service evaluation, quality assurance and risk management

ESTRO 2024

To provide more insight staffing levels and experience were correlated with the timeframes of the data captured as a whole. In-depth analysis for reasons demonstrated some commonalities, primarily the spikes in pre-treatment activities and treatment data entry all occurred at times of insufficient staffing, increased regularity of staffing changes, new or inexperienced staff in these areas. In the data entry area, it was clearly seen that errors increased when the staff allocated to that area had to be moved to work clinically on a machine due lack of staffing, resulting in data entry elements being completed by staff with conflicting clinical priorities rather than their sole focus. Other considerations such as introduction of change of practice or new developments offered a correlation with data entry error increase, examples being new image scheduling introduction, DIBH introduction and increased number of new staff members. The spikes in pre-treatment activities which is mainly CT was of a similar vane, but this time it was more due to staff being pulled into the area in an adhoc way due to staffing when they had maybe not been on the modality for a period of time. This constant changing of staff provided areas of uncertainty and lack of awareness leading to increased levels of errors reported.

Figure 1 – Safety barriers

Armed with this information actions of improvement where identified in conjunction with the staff group. These included changes to staffing and workforce allocation considering a safe staffing level in all areas of the department data and also investigate ways to minimise inconsistent rotating of staff. Also more engagement with staff into the type of Datix’s being submitted such as monthly canva posters creating a forum for conversation and improvement. Evaluation of the impact of the changes is key within a reasonable timeframe by analysing further trends in error reporting.

Conclusion:

Locally trending errors and incidents within radiotherapy has proved a useful tool in understanding the types of infrastructure changes that influence when and why errors occur. It has allowed us to not only retrospectively look at why this happen but also prospectively highlight situations where errors are more likely to happen and take actions to alleviate this. This information can also feed into workforce planning elements contributing to a minimum safe staff level and rotational pattern.