S1515
Interdisciplinary - Quality assurance and risk management
ESTRO 2026
Proffered Paper 2341 The power of language in patient safety Cristíona J Logan, Helen Best, Úna Findlay, John Rodgers Medical Exposures Group, UK Health Security Agency, Oxford, United Kingdom Purpose/Objective: In May 2025 two new guidance documents were published within the UK to support radiotherapy providers to enhance patient safety: “Advancing Safer Radiotherapy” (ASR) and the “National Patient Safety Radiotherapy Event (RTE) Taxonomy”. 1,2 Both documents were developed in collaboration with a multidisciplinary team drawn from the radiotherapy community, professional bodies and patient representation.These publications were produced in response to emerging challenges identified via the national event learning system (ELS) and to reflect contemporary developments within radiotherapy and patient safety. The important changes to language reflected within both documents and the potential impact will be explored here. Material/Methods: The development pathway of both guidance documents is illustrated within figure 1.
Prostate treatments consistently showed the GPR, with both higher mean values and lower variability compared to other sites. This reflects the high degree of planning homogeneity, standardized IGRT protocols, and consistent patient preparation. For lung treatments, GPR variability has decreased notably since 2021, indicating improved stability, likely due to increased use of replanning strategies and respiratory motion management. A similar, though smaller, improvement was observed for abdominal sites.In contrast, pelvic treatments showed a higher variability and slight decline in mean GPR, requiring further investigation. No significant changes in GPR were observed for H&N and breast across the studied years.Figure 2 summarizes the percentage of fields out of tolerance and related causes. The most frequent were patient positioning and anatomical changes. Deviations linked to immobilization systems and “unknown” causes have decreased, reflecting users’ growing experience with transit image analysis, while the “unclassified” group includes remaining unmatched reports.
A programme of work has subsequently been implemented to support radiotherapy providers adopt the guidance and periodically assess impact, including audit tools, webinars and workshops. Results: The terminology within the published guidance has been updated to foster a positive safety culture and promote continual review and improvement. The main changes and rationale have been summarised in table 1.
Conclusion: In vivo dose measurements, when analyzed
longitudinally over time, can serve as powerful quality indicators in radiotherapy. Such monitoring not only ensures that treatments are delivered according to established standards, but also enables the detection of variations in clinical practice, thereby supporting continuous quality improvement. Keywords: in-vivo dosimetry, quality indicator
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