BMJ  2007;334:381 (24 February), doi:10.1136/bmj.39128.703692.3A

Letters

Radiotherapy harm

Culture of secrecy must be tackled

The Royal College of Radiologists welcomes the chief medical officer's editorial on reducing harm from radiotherapy.¹ In the five years to April 2006, only 211 incidents of a dose greater than intended were reported under the IR(ME) regulations.² Many of these were correctable by adjusting subsequent treatment. Patient injury is a rare event; this is as it should be for a non-emergency treatment given routinely to patients with an established diagnosis.

In June 2006 the Royal College of Radiologists set up a multidisciplinary working party to identify measures to prevent and mitigate errors in radiotherapy. One of the main obstacles to this work is the culture of secrecy surrounding radiotherapy incidents. The system for reporting radiotherapy incidents in the United Kingdom is dysfunctional: the results of inquiries are secret; there is no dissemination of learning; errors are repeated; and public confidence is eroded.¹ Most of the incidents reported under the IR(ME) regulations remain confidential and can only be identified under the Freedom of Information Act.² The full report of the inquiry into the Leeds incident has still not been published despite the fact that it contains a number of recommendations for practice nationally.

Open publication, as in the Glasgow incident, is the exception but should be the rule. This could be facilitated by establishing a website to host anonymised reports of inquiries. At the very least, a confidential system to disseminate learning on the National Confidential Enquiry into Perioperative Deaths (NCEPOD) model should be established. This would involve collaboration between the National Patient Safety Agency, the Health Protection Agency, and the Healthcare Commission. Change in the UK is essential if we are to improve our learning from errors.

Faculty of Clinical Oncology, Royal College of Radiologists, London W1B 1JQ

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Competing interests: None declared.

References

1. Donaldson L. Reducing harm from radiotherapy. BMJ 2007;334:272. (10 February.)[Free Full Text]
2. Over 200 hurt or killed by botched radiation. Sunday Times 2006 April 30.

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Relevant Article

Reducing harm from radiotherapy

Liam Donaldson
BMJ 2007 334: 272. [Extract] [Full Text] [PDF]