Quarterly report on Grade-1 radiotherapy events reported to the ASN, classified using the ASN-SFRO scale – second quarter of 2009
Between 1 April and 30 June 2009, seven events were classified as Grade 1 on the ASN-SFRO scale. These events, not expected to have health consequences for the patients, are nonetheless analysed for lessons learned (particularly in terms of organisation) and to ensure they do not reoccur.
Each event concerned only one patient.
Of the seven events:
- Four involved incorrect positioning of the patient due to use of inappropriate reference points or confusion between left and right (during 10 treatment sessions);
- Two reports involved a beam shaping error (errors in mask production, masks forgotten);
- One event involved the administration of an inappropriate dosage due to a table height error (during 6 treatment sessions).
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. The ASN systematically examines the corrective measures proposed after the centre's analysis of the event.
The corrective measures for the period in question included formally documenting precise procedures for beam positioning, mask production and checking the patient's position.