A short presentation introducing the policies and guidance section of the IGRT course

1. This presentation refers to UK based
documentation and recommendations
Guidance relating to verification,
safety and IGRT

2. National Radiotherapy Advisory Group
(NRAG)
 NRAG report 2007: "Radiotherapy: developing a world
class service for England“ – dated but provides context
 Makes recommendations for short and long term action
for improving radiotherapy services.
 3D technology for imaging, planning and treatment
delivery is currently considered the minimum
expectation.
 IMRT and 4D adaptive radiotherapy, which can target
tumours more accurately, is already commonplace.
 All replacement technology should be equipped to
provide this.
 Estimates that over 90 extra linacs would be needed
over the next 10 yrs. 60 needed now.
 6-35 linacs need replacing each year across the country.
 IGRT is an expected standard of care and improved
accuracy is expected to reduce side effects, expand the
possible uses for radiotherapy and improve outcome.
 The workforce need to be trained (knowledge and skills)

3. National cancer peer review
measures: radiotherapy measures
 Published by the National Cancer Action Team
in 2008
 They detail a range of ‘measures’ that should
be met and how they can be demonstrated
 They cover a range of issues relevant to
safety in radiotherapy, error reporting and
reduction, staff training and competency,
treatment verification protocols and include
specific measures for in vivo dosimetry, IMRT
and brachytherapy

4. Towards Safer Radiotherapy (2008)
 RT is an increasingly evolving, changing and
complex process.
 Heavy reliance on automation.
 Staffing levels, skills mix, regular training and
competency updates are deemed essential.
 Workload and stress is a significant factor for
increasing error.
 This document has a clear focus on the
ultimate goal of an accurate delivery of dose.
IGRT is just one aspect of ensuring this.
 All departments should have access to on-
treatment verification imaging.
 In-vivo dosimetry should be routinely used at
the beginning of treatment for most patients.

5. Classifying errors

6. What causes the errors?
 Fatigue
 Introduction of New Practice/ lack of documentation
 Human Error
 Increased use of Technology
 Distractions
 Negligence / Poor Practice
 Rushing
 Lack of training, competence, expertise
 Automation
 Poor team working
 Poor communication
 Changes
 Patients

7. Where are the Errors?
 Alignment errors (geographical miss)
 Calculation errors
 Preparation, planning, marking or simulator
 Left/right
 Input errors
 Wrong patient/wrong documentation
 Shielding error
 Scheduling
 Ant/post confusion
 Software issues
 Others

8. Public Health England: Safer
radiotherapy: error data analysis
 Analysis of radiotherapy errors and near misses
reported voluntarily by NHS radiotherapy
departments.
 Reports published for the wider radiotherapy
community to learn from as a means of improving
safety in radiotherapy
 Available at:
https://www.gov.uk/government/publications/safer
-radiotherapy-error-data-analysis-report
 They make for interesting reading.

9. Guidance relating more specifically
to IGRT

10. On Target 2 (2021)
 Is based on an extensive review of the available
evidence and makes recommendations for
treatment verification protocols for individual
treatment sites. Updates the original document
 All forms of IGRT are reviewed
 The concepts and practices relating to sources
and types of error and how these can be
corrected for i.e. the design principles of an
overall verification imaging protocol, can still be
applied to the wider use of IGRT though
 A really good document for understanding the
key concepts underpinning the use of portal

11. Image Guided Radiotherapy (IGRT)
Clinical Support Programme in England
2012 -2013
 This document is aimed to provide recommendations
on service development for IGRT.
 They reviewed clinical practice
 Gave support in developing protocols
 Recommendations for training
 This document gave evidence to the government and
so the Radiotherapy Innovation Fund (RIF) was set
up with all departments applying for funding to
improve their service provision for IGRT.