Training activity information
Details
Assess the impact of an error in patient treatment delivery, write an incident report and recommend a strategy for correction
Type
Developmental training activity (DTA)
Evidence requirements
Evidence the activity has been undertaken by the trainee​.
Reflection on the activity at one or more time points after the event including learning from the activity and/or areas of the trainees practice for development.
An action plan to implement learning and/or to address skills or knowledge gaps identified.
Considerations
- Dose delivery or geometric error
- Calculations to establish the magnitude of error relative to local and/or IR(ME)R tolerances
- Communication with the multidisciplinary team
- Error reporting and recording as appropriate
- Root cause analysis
- Legislation and guidance
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
- What happened during the treatment error?
- What are the potential dosimetric and clinical consequences for the patient?
- What are the departmental procedures for incident reporting?
- What information needs to be included in the report?
- What factors should be considered when recommending a corrective strategy?
- Have you discussed the incident with your supervisor and other relevant staff?
- How will you assess the impact of the error?
- What factors will you consider when recommending a corrective strategy?
- How do you feel about being involved in the analysis of a clinical error?
In action
- How are you quantifying the dosimetric impact of the error?
- What factors contributed to the error occurring?
- How are you structuring the incident report to accurately and objectively document the event?
- What are your recommendations for preventing similar errors in the future and mitigating the impact of this specific error?
- What relevant guidelines or protocols are you considering?
- Are you able to accurately assess the extent and potential impact of the treatment delivery error?
- Are you identifying the root causes of the error?
- Is your incident report clear, factual, and comprehensive?
- Are your recommendations for correction practical and effective?
- If you encounter difficulties in assessing the impact of the error or determining the root causes, where are you seeking further information or guidance?
- Are you collaborating with other team members to ensure a thorough investigation and appropriate recommendations?
- Are you considering different strategies for communicating the incident and lessons learned to relevant staff?
On action
- What were the details of the treatment delivery error? What data and information were gathered to assess the impact? What was the estimated dosimetric or clinical impact on the patient? What were the key elements included in the incident report? What strategy for correction or mitigation was recommended?
- What did you learn about your analytical skills in assessing the impact of incidents, your attention to detail in documenting events accurately, and your ability to formulate appropriate and effective corrective strategies? Did you identify any areas where your understanding of error analysis or risk management could be enhanced?
- How will this enhance your understanding of the importance of error prevention and management? How will this improve your ability to assess the impact of errors and contribute to incident reporting and analysis? What further knowledge of error classification systems and risk management strategies would be beneficial?
Beyond action
- Looking back at the error you assessed, how has your understanding of the potential impact of treatment errors and the importance of incident reporting evolved?
- How has this experience influenced your approach to identifying potential risks and contributing to a culture of safety?
- Have you been involved in or observed other discussions or analyses of treatment errors since this training activity? How did your learning from this experience inform your contributions and / or understanding of it?
- How has your understanding of error impact assessment and incident reporting since contributed to your role in ensuring patient safety and promoting learning from adverse events?
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 3 |
Outcome
Generate, adapt and evaluate treatment plans using complex techniques. |
| # 7 |
Outcome
Assess the quality of practice and make recommendations for improvements. |
| # 8 |
Outcome
Practice effectively as part of a multidisciplinary team to provide safe, patient centred radiotherapy treatments. |