Abstracts ASN Report 2019

ӈӊՌ łĹ ŇĻĸ ĸʼnĸŁŇņ ŅĸŃłŅŇĸķ ļŁ ӅӃӄӌׇŊĸŅĸ ŅĴŇĸķ ĿĸʼnĸĿ ӄׇłŁ ŇĻĸ і ņĶĴĿĸє ĻŅĸĸ ĸʼnĸŁŇņ ļŁ ӅӃӄӌׇŊĸŅĸ ŅĴŇĸķ ĿĸʼnĸĿ ӅׇłŁ ŇĻĸ і ņĶĴĿĸє Ļĸņĸ ŇĻŅĸĸ ĸʼnĸŁŇņ ĶłŁĶĸŅŁ ŇĻĸ ņŇĸŅĸłŇĴĶŇļĶ treatment of the target twice in the same session, a wrong-side error in the treatment of a cancer of the oral cavity and a wrong- side error in a proton radiotherapy treatment of an eyelid lesion. As in the preceding years, these events reveal organisational weaknesses in: Ҋ the management of the movement of patients’ medical files; Ҋ the validation steps which are insufficiently explicit; Ҋ 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 an impact on treatment amplitudes, or the deployment of a new technique or practice, are all risk factors. GRAPH 6 Percentage of conformity of the facilities concerning the management of events giving rise to corrective actions in 2019 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Reporting culture and organisation ȇƏǼɵɀǣɀً ƳƺˡȇǣȇǕ ƬȒȸȸƺƬɎǣɮƺ ƏƬɎǣȒȇɀً building on lessons learned ɀɀƺɀɀǣȇǕ ƬȒȸȸƺƬɎǣɮƺ ƏƬɎǣȒȇ ƺǔǔƺƬɎǣɮƺȇƺɀɀ \Ǽƺ ٮ Ƴƺ ٮ IȸƏȇƬƺ ÁǣǕǝɎƺȇƺƳ ǣȇɀȵƺƬɎǣȒȇ Ȓǔ Ɏǝƺ ȸƏƳǣȒɎǝƺȸƏȵɵ ƬƺȇɎȸƺ Ȓǔ Ɏǝƺ ¨ƺɖȵǼǣƺȸɀ ¨ȸǣɮƏɎƺ RȒɀȵǣɎƏǼ ٢¨Əȸǣɀ٣ After observing organisational malfunctions during Ɏǝƺ ǣȇɀȵƺƬɎǣȒȇ Ȓǔ ׏ ژז xƏȸƬǝ א ׎׏ ژח ǣȇ Ɏǝƺ ȸƏƳǣȒɎǝƺȸƏȵɵ centre of the Peupliers Private Hospital of the Ramsay-Santé group, ASN conducted another ǣȇɀȵƺƬɎǣȒȇ Ȓȇ א ׏ ژ ƏȇƳ …ژאא ƬɎȒƫƺȸ א ׎׏ ח ِ Áǝǣɀ ǣȇɀȵƺƬɎǣȒȇ ran in parallel with a control visit by the Île-de-France Regional Health Agency (ARS). It emerged from Ɏǝǣɀ ژ ȇƺɯ ǣȇɀȵƺƬɎǣȒȇ ɎǝƏɎ Ɏǝƺ ƬƺȇɎȸƺ ټ ɀ ȸƏƳǣȒɎǝƺȸƏȵɵ activities are carried out at a sustained pace ɯǣɎǝ ژ ȵƺȸɀǣɀɎƺȇɎ ɖȇƳƺȸɀɎƏǔǔǣȇǕً ǼƺƏɮǣȇǕ Ɏǝƺ ȅƺƳǣƬƏǼ personnel little margin to cope with unexpected ƏȇƳ ژ ɖȇǔȒȸƺɀƺƺȇ ƺɮƺȇɎɀِ Áǝǣɀ ǼƺƏƳɀ ɎȒ Ə ɯȒȸǸ ɀǣɎɖƏɎǣȒȇ that is a potential source of risks and errors for Ɏǝƺ ژ ȵƏɎǣƺȇɎɀِ Áǝƺ ɀǝȒȸɎƬȒȅǣȇǕɀ ƬȒȇƬƺȸȇǣȇǕ themedical organisation, medical physics, the work of the radiographers, and shortcomings in themanagement of the quality management system, the prospective risks analysis, document management and the reporting and analysis Ȓǔ ژ ƏƳɮƺȸɀƺ ƺɮƺȇɎɀ ǝƏɮƺ Ǖǣɮƺȇ ȸǣɀƺ ɎȒ Ə ƬȸȒɀɀ ٮ ƬǝƺƬǸǣȇǕ procedure that will continue in 2020. SUMMARY In radiotherapy, the safety fundamentals are in place (equipment verifications, medical staff training, quality and risk management policy) and the quality initiatives are progressing. The prospective risk analyses however remain relatively theoretical and are insufficiently deployed prior to organisational or technical changes. Given the maturity of the sector with regard to patient radiation protection, ASN is reducing its inspection frequencies, but given the diversity of situations encountered, the centres displaying vulnerabilities or particular risks will continue to be subject to particular scrutiny and more frequent monitoring in 2020. 208 ASN Report on the state of nuclear safety and radiation protection in France in 2019 ׎ ٲ ו MEDICAL USES OF IONISING RADIATION