Quarterly report on Grade-1 radiotherapy events reported to the ASN, classified using the ASN-SFRO scale – Third quarter of 2008

Paris, december 3, 2008

On 1 July 2008, the French Nuclear Safety Authority (Autorité de Sûreté Nucléaire – ASN), the French Society of Radiation Oncology (Société Française de Radiothérapie Oncologique - SFRO) and the French Society of Medical Physics (Société Française de Physique Médicale - SFPM) updated and validated the ASN/SFRO scale classifying radiation-protection events affecting patients undergoing a medical radiotherapy procedure. The scale had previously been in use for a year on a trial basis.
 
The ASN initially reported on events classified as Grade 1 on the ASN/SFRO scale by routine incident reports and since 1 July, these reports have been condensed into a quarterly report published on the ASN's website. Grade-1 events affecting a cohort of patients, and also events classed as Grade 2 or above, continue to be reported individually on the ASN's website.
 
Between 1 July and 30 September 2008, ten events were classified as Grade 1 on the ASN-SFRO scale. These events relate to an anomaly in positioning the patient (7 cases), an error in identifying patients occurring during a single radiotherapy session (2 cases) and forgetting the lead shield during one session for a single treatment beam (1 case). These Grade-1 events affected the dose, but since they were detected during treatment, no clinical consequences for the patients are expected.
 
Grade-1 events are investigated by the ASN either during a specific inspection or during the annual inspection that the ASN carries out at all radiotherapy centres. For each of these events, the ASN reviewed all the proposed corrective measures. Such measures include, for instance, improving the procedures for selecting the patients' electronic files, checking the data relating to positioning and automating some of the checking, such as the positioning of the treatment table, using software that verifies and records the treatment parameters.