of the centres inspected. ASN nevertheless notes a boost in progress in 2024 with 49% of the centres deploying the procedures satisfactorily, compared with 36% in 2022 (see Graph 2). ASN also observes an increase in the participation of radiotherapists in these procedures in the inspected centres over the last two years. Furthermore, regular assessment of the corrective actions implemented and updating of the prospective risks analysis on the basis of the lessons learned from the events reported internally, which is obligatory pursuant to the abovementioned ASN resolution 2021DC-0708 of 6 April 2021, are vital in order to improve treatment quality and safety. The ability of a centre to deploy a risk management procedure was again subject to specific investigations in 2024. These investigations reveal that: ∙Although the requirements for quality and safety management in radiotherapy departments are satisfied in the majority of cases, there are still disparities between centres. Nearly two-thirds of the departments have updated their prospective risks analyses (63%). The situations considered to be unsatisfactory concern the departments whose prospective risk analyses have not taken into account the lessons learned from internal or external events (those from other centres for example, disseminated by the ASN publications such as the “Patient safety” bulletins and “Learning from experience” sheets, the deployment of new practices or organisational changes when the technical platforms evolve. The impact of an organisational or technical change on the operators’ activity is effectively not always analysed, yet these changes are potential sources of disruption, particularly in the organisation of treatments and work practices and can weaken the existing lines of defence. ASN has analysed the significant radiation protection events involving laterality errors occurring in external-beam radiotherapy in 2023-2024 from the human and organisational factors aspect The notification of several ESRs involving laterality errors in 2023-2024 led ASN to analyse them from the HOF aspect using the significant event reports transmitted by the centres. The results of this analysis were compared with the data in “Patient safety”’ bulletin No. 6 (May 2014) to understand how they are evolving. The results of the analysis show firstly that six of the seven laterality errors that occurred in 2023-2024 were due to errors at the medical prescription stage (prescription errors, conflicting information in the associated documents), whereas in the 2010s, delineation errors(*) were the main cause of laterality errors. The numerous checks implemented at the simulation, delineation and dosimetry stages did not detect the laterality error made at the medical prescription stage, in particular because the medical staff involved (radiographer, dosimetrist, medical physicist) use the documents containing the error (prescription and associated documents) to carry out their checks. Laterality errors are explained in particular by four types of root causes, the first three of which concern the medical prescription stage : missing elements (target volume not visible due to the surgical procedure, patient’s file incomplete, no team review of the file, disappearance of anatomical landmarks with the technological and surgical developments, etc.), elements leading to confusion (previous history of multiple left / right cancer, automatic contouring of both organs in paired organs, reworked area on the image, surgical staples, calcification or nodule on the contralateral organ, zoomed images, etc.), potential laterality problems (16% of adults have difficulty distinguishing right from left) and the deterioration of the work conditions for all the personnel (staff shortages, excessive workload, interruptions, etc. figure in the ESR reports transmitted by the centres). In addition, the level of severity of these ESRs is higher. As the significant event reports lacked data on the doses received by the patients, two criteria were studied: the level of severity declared on the ASN‑SFRO scale and the number of sessions concerned by the laterality error. The seven ESRs studied in 2023-2024 were rated level 2 on the ASN-SFRO scale, whereas in the 2010s, the majority were rated level 1. The number of sessions targeting the “wrong side” is higher in the 2020s than in the 2010s. They can now concern the entire treatment due to late detection of the error (posttreatment follow-up consultation). This analysis was presented to the SFRO in October 2024. The findings put forward by ASN during the presentation were confirmed and supplemented: making out the medical prescription is identified as a risk-prone stage. These ESRs occur essentially after a surgical procedure which has rendered the tumour undetectable and/or following several cancers affecting or having affected both sides. The prescription error can arise at earlier stages, such as during the multidisciplinary consultation meeting or when entering the laterality in the patient’s file. The means of detecting a laterality error can be diminished when the tumour is no longer detectable, particularly in post-surgical situations (post‑operative, surgical progress), in the case of a bilateral disease or when the irradiation technique no longer allows the treatment fields to be viewed on the skin (VMAT). The checks put in place to prevent laterality errors when performing the procedure are not appropriate to allow such prescription errors to be detected before performing the procedure. Beyond the actions proposed by the SFRO (check‑list, questioning the patient about the laterality, meetings between interns and senior radiotherapist after the centring CT scan), ASN underlines the benefit of analysing the medical prescription activity in order to better understand it, and in particular the constraints encountered and the action levers to put in place to prevent similar events from occurring. The Authority for Nuclear Safety and Radiation Protection (ASNR) will publish a “Treatment safety” sheet on the subject in the first quarter and will be associated with the WG set up by the SFRO on laterality and re-irradiation errors. * Action of marking the contour of an organ on a medical image. Inspection of a centre after two level-2 ESRs were notified in the space of one month An inspection was organised following the occurrence of two level-2 ESRs in a short space of time in the same radiotherapy centre, notified to ASN on 25 March and 25 April 2024 respectively. The first ESR concerned a laterality error (right-left reversal) that occurred during treatment preparation, when selecting the target organ at the delineation stage. The second ESR concerned an error resulting from failure to take into account the overlapping of treatment planes. It occurred during the treatment of a patient undergoing stereotactic treatment on three locations simultaneously. These ESRs were rated level 2 on the ASN‑SFRO scale. They occurred in a context of sustained activity with a very significant increase in use of the stereotactic technique spanning several months now, an ongoing change of accelerator and a shortage of radiographers. The impact of these situations or developments had not been sufficiently grasped in the prospective risk analysis. The inspection moreover highlighted the deficiencies in the management of the treatment preparation process, with a large percentage of patient files being finalised on the very day the treatments started, and well as shortcomings in assessing the human resources required for the level of activity of the centre. Lastly, the inspection revealed the need to analyse the events in greater depth, involving all the stakeholders in deciding on the corrective actions and assessing the robustness of the safety barriers put in place. ASN Report on the state of nuclear safety and radiation protection in France in 2024 221 Medical uses of ionising radiation 07 01 02 03 04 05 06 08 09 10 11 12 13 14 15 AP
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