ESTRO 2025 - Abstract Book

S4301

RTT - Service evaluation, quality assurance and risk management

ESTRO 2025

Material/Methods: An analysis of 12 months data reported between November 2023 and October 2024 within the UK national ILS was completed. All severities of RTE were included in the study. All coded CF were included and assigned to the relevant stage in the radiotherapy pathway indicated within reporters coded taxonomy. To establish relationships between different radiotherapy pathway areas and CF a heat map detailing the percentage of CF associated with each stage along the patient pathway was produced Results: There were 11,068 RTE reported nationally for this time period, multiple CF can be assigned to each RTE. In total there were 14,079 CF. The heat map (figure 2) indicates that individual and procedural CF are the most frequently associated CF along much of the patient pathway. The heat map also indicates that technical CF generate a significant percentage of events within the on treatment phase, predominantly through treatment and imaging equipment failure. Furthermore teamwork/ management/ organisation CF feature within staff management.

Conclusion: Radiotherapy is highly complex and there are multiple factors constantly influencing many points along its pathway. Recently there has been an increasing focus on the complex interplay between technical, individual, group, organisational and social factors. This study indicates the importance of reporting providers using a systems approach utilising the full CF taxonomy to help establishing resilient and safe systems rather than explaining events on individual fallibility.

Keywords: Incident learning system, systems approach

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