ASN Report 2018

2.3.3  –  Significant events in external-beam radiotherapy In 2018, 132 significant events concerning radiotherapy were reported. In the last few years, ASN has noted a significant reduction in the ESRs reported by radiotherapy departments. Indeed, as from 2008, some 240 ESRs were notified each year. This phenomenon must be analysed with the assistance of the radiotherapy professionals to find out the reasons for this drop in numbers. Most of the events reported in 2018 concern patient radiation protection, and the majority of them are not expected to have any clinical consequences. Fifty-three percent of the events in 2018 were rated level 1 on the ASN-SFRO. Five events in 2018 were rated level 2 on the ASN-SFRO. These five events concern one volume error during palliative treatment of cervical metastases, three laterality errors in patients treated for breast cancer, lung cancer and sinus cancer respectively, and one error in the dose delivered to a patient. As in the preceding years, these events reveal organisational weaknesses in: ∙ ∙ the management of the movement of patients’ medical files; ∙ ∙ the validation steps which are insufficiently explicit; ∙ ∙ the keeping of patients’ files in a manner that provides an overall view and gives access to the necessary information at the right time. Variations in practices within the same centre, frequent task interruptions, a heavy and uncontrolled workload with, among other things, an impact on treatment ranges or the deployment of a new technique or practice, constitute situations which can foster errors. ESRs rated level 2 on the ASN‑SFRO are always subject to immediate inspection by the ASN division concerned.  AUVERGNE-RHÔNE-ALPES REGION  Tightened surveillance of the Lucien‑Neuwirth Cancerology Institute (ICLN) in Saint‑Priest‑en‑Jarez (Loire département ) In 2018, ASN continued the tightened surveillance of the ICLN radiotherapy department, which began in 2017. A first inspection carried out by ASN on 14 and 15 September 2017 had revealed conflictual relations within the radiotherapy department, resulting in insufficient communication between professionals and deadlock situations, particularly regarding the medical physics organisation and management of quality and safety. These findings led ASN to subject this department to tightened monitoring in 2018 through two inspections. A second inspection on 25 and 26 January 2018 aimed at assessing the conditions of performance and safety of the stereotactic radiotherapy activity. This inspection was carried out jointly with the Auvergne‑Rhône‑Alpes ARS in the presence of experts: it led the inspectors to conclude that the quality and risk management was insufficient and that the centre’s ability to conduct a stereotactic radiotherapy activity was not demonstrated. Given this situation, the Auvergne‑Rhône‑Alpes ARS decided to suspend the stereotactic radiotherapy activity at the ICLN for six months. On 11 July 2018, a further inspection conducted by a joint team of ARS and ASN inspectors was organised to check the effective undertaking of risk management actions. The inspection team observed in particular the development of a positive momentum in the radiotherapy department. ASN will continue to monitor this centre in 2019, by verifying in particular the results of the work to harmonise and formalise the practices and to formalise the prospective risk analysis.  BOURGOGNE-FRANCHE-COMTÉ REGION  Inspection of the Bourgogne Cancerology Institute (ICB) on its Chalon‑sur‑Saône site On 20 and 21 June 2018, ASN conducted an inspection of the Bourgogne Cancerology Institute (ICB) on its Chalon‑sur‑Saône site, assisted by two experts. This inspection confirmed the strong points of this radiotherapy centre, and in particular the competence and the professional conscience of the healthcare personnel involved in the safety of the treatments delivered to the patients. It did however also reveal malfunctions and deviations which call for organisational and functional changes. More specifically, the human resources of the centre are currently below European standards for the number of patients treated, which necessitates sound management of skills and jobs pending the commissioning of a new accelerator. The age of one of the machines and the potential for failures, the prospect of the forthcoming retirement of a number of physicians and the coexistence of heterogeneous medical practices are also risk factors to be taken into account. Given this situation, ASN asked the activity supervisors to establish an action plan, which they presented to the ASN Dijon division and the ARS on 11 October 2018. During this meeting, the ARS and ASN underlined the quality of the action plan which had been drawn up collegially by the medical corps and the staff of the ICB. In 2019, in collaboration with the ARS, ASN will regularly monitor the progress of the plan through follow-up meetings or inspections. ASN report on the state of nuclear safety and radiation protection in France in 2018  211 07 – MEDICAL USES OF IONISING RADIATION 07