Quarterly statement of radiotherapy events reported to ASN, classified as Level 1 on the ASN-SFRO (French Nuclear Safety Authority - French Society of Radiation Oncology) scale - 4th quarter 2008
Events after 1st July 2008, classified as level 1 on the ASN-SFRO scale and which ASN initially reported via the incident report system, are summarised in an overall quarterly statement which was published on the ASN Internet site. Events classified as level 1 and relating to a group of patients, as well as those classified at level 2 or higher, are the subject of individual bulletins posted on the ASN Internet site.
ASN have now published their second overall statement corresponding to the 4th quarter of 2008.
Between 1st October and 31st December 2008, nine events were classified as level 1 on the ASN-SFRO scale. There are no expected consequences for the health of the patients from these events. Each event relates to a single patient. The majority (7 cases) were each the result of a single treatment session. They were due to anomalous positioning of the patient (3 cases), to application of a session of treatment to the opposite side to that which had been planned (1 case) or to an error in the shape or orientation of the beam (3 cases and 1 case respectively). The last event, which was repeated over 3 treatment sessions, was linked to a radiation attenuation-filter having not been installed.
Level-1 events are subject to investigations by ASN, either in the form of a dedicated inspection, or as part of the annual inspection that ASN conducts at all radiotherapy centres. ASN systematically examines the corrective measures proposed after the event has been analysed by the centre. In centres where the analysis of the event has been concluded, corrective measured have, for example, consisted of:
- Modification of access rights to the software for verification and entering of the treatment parameters, in order to limit data modification to a restricted number of suitably trained individuals;
- Redistribution of tasks between the operators who work in partnership.