ASN Report 2020

In order for there to be real continuous improvement in treatment quality and safety, greater efforts must be devoted to regularly assessing the corrective actions put in place, involving all the personnel and using the lessons learned to review the prospective risk analysis, which is mandatory pursuant to the abovementioned ASN resolution 2008-DC-0103 of 1 July 2008. In addition to the verifications performed, the ability of a centre to deploy a risk management procedure was again subject to specific investigations in 2020. These investigations reveal that: ∙ Although the requirements for quality and safety management in radiotherapy departments are satisfied on the whole, there are still disparities between centres. The prospective risk analysis for example, which is mandatory, is only available and complete in half of the inspected centres. ∙ More generally, further to the inspections carried out since 2016, ASN considers that implementation of the risk management procedure is only satisfactory on the whole in half of the inspected centres. These are the centres in which management has defined a policy with shared, assessable and assessed operational objectives, has communicated on the results of this policy and allocated the necessary resources, in particular, to the operational quality manager. Lastly, ASN still notes in 2020 that the technical, organisational or human changes are not sufficiently planned for in advance. The impact a change can have on the operators’ activity is not always analysed, despite the fact that these changes can weaken the exist- ing lines of defence. The lessons learned from the inspections carried out in 2020 show that, when a new technique is deployed, “Wrong-side” errors, the need to remain attentive throughout the radiotherapy pathway of the patient So-called “wrong-side” (or laterality) errors are frequent causes of Significant Radiation Protection Events (ESRs) reported to ASN and most often rated level 2 on the ASN‑SFRO scale. In 2014 (in collaboration with the professionals), ASN published a Patient Safety newsletter dedicated to this type of error (No. 6). Since then, out of a total of 29 events rated level 2 and two events rated level 2 and higher over the 2014–2020 period, 11 “wrong-side” errors have been reported, 2 of them in 2020. These errors can occur at various stages from the beginning to the end of a patient’s radiotherapy treatment pathway: ཛྷ when preparing the medical prescription, whether handwritten or computerised, by failing to consult the documents of the medical file (surgical or anatomy/ pathology report) to check the laterality; ཛྷ during imaging, due to an error or lack of left/right position indications on the images; ཛྷ during dosimetric planning; ཛྷ when defining the patient positioning references; ཛྷ when carrying out one or more radiotherapy sessions. To prevent these errors, it is vital to ensure traceability of all the paired organs in all the documents throughout the patients’ treatment pathway. Any doubt must be lifted by a collegial review of the radiotherapy file. Lastly, the active participation of the patient or the person accompanying them is key to preventing this type of error. The importance of taking prior radiotherapy treatments into account: example of a “re-irradiation” due to a second cancer One Significant Radiation Protection Event (ESR) that occurred in September 2020 provided a reminder of the need to record prior radiotherapy treatments in the patient’s computerised medical file. The patient had undergone treatment for a gynaecological cancer in a centre two years previously. Treated in a different centre in 2020 for a lung cancer, the doses delivered during this treatment were duly defined taking into account those delivered during the first treatment. However, when the patient was admitted as an emergency case a few months later for treatment of the lumbar vertebrae, the first treatment was omitted when preparing the third treatment, resulting in overlaps in the fields of irradiation. This error could have been avoided if the treatment data from the first centre had been digitised and integrated in the computerised file of the second centre treating the patient. The effectiveness of cancer treatments means that more and more patients can receive several radiotherapy treatments in the course of their lifetime, following a relapse, a second cancer or an extension of the disease. The “re-irradiations” can be staggered over periods ranging from a few weeks to decades, and constitute a new issue in patient radiation protection to which ASN must be particularly attentive. Thirty events have been reported to ASN over the last ten years, some having serious consequences for the patients. It is sometimes difficult, if not impossible, to identify and take into account a patient’s radiotherapy treatment history, depending on how far back the previous treatment dates and the centre in which it was carried out. Consequently, in June 2020 ASN published a Patient Safety newsletter devoted to prior radiotherapy treatments. Good practices and recommendations are set down, especially the need to take into account the prior irradiations in the prospective risk analysis. The importance of having a complete radiotherapy file is also emphasized, as is the need, when a previous irradiation history has been identified, to digitise and integrate in the computerised file all the data concerning the previous irradiations. ASN Report on the state of nuclear safety and radiation protection in France in 2020 217 07 – MEDICAL USES OF IONISING RADIATION 07