Public Board of Directors papers 29.09.22

1. Safe

1.4 – Learning - Patient Safety Incidents

Agreed learning and revised severity outcome following executive reviews August 2022 Ref Description Root cause Learning

Outcome

Root cause 1- Failure to follow correct process in relation to clicking multileaf collimator (MLC) on/off at pre-treatment planning and checking stage to check MLC positions prior to plan locking (plan 1). Root cause 2- Failure to delete the original incorrect plan from the Oncology Management System (OMS) (plan 2).

Incorrect plan used for 4/5 fractions of radiotherapy resulting in irradiation of anatomy outside of treatment field.

Alert triangle to communicate the incident learning and requirement to follow process. IRMER ref 632948390

W69938 CNS

Minor

1. Safe

2 transplant co-ordinators to check the proforma prior to issuing to consultant for final check. Proformas to be completed 1 week prior to admission to allow for checks in a timely manner. SOP to be updated in Q-Pulse. Risk assessment to be completed and discuss with Digital team re-starting development of CWP forms. Transplant team to complete audit.

Deviation from process for monitoring of CMV status in a transplant patient.

Human errors and System error (Current manual process for completing transplant proformas is sub-optimal).

W69551 CNS

Moderate

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