Introduction

Several methodologies can be used to analyse safety-related events that occur in healthcare organisations. The Prevention, Recovery and Information System for Monitoring and Analysis (the PRISMA-medical approach) provides a structured framework that is focused on the identification of the root causes of such events. It classifies these causes into technical, organisational, human, and patient-related factors, in line with the Eindhoven Classification Model [1].
 

PRISMA-RT network in the Netherlands

Multiple radiotherapy departments in the Netherlands adopted the PRISMA methodology in 2008 for the analysis of safety events. This shared approach laid the foundation for collaboration and led to the creation of a centralised database that aggregated root causes identified by the different departments. Building on this initiative, the PRISMA-radiotherapy (PRISMA-RT) network emerged in 2008 as a cooperative platform among 20 radiotherapy institutions that were dedicated to improving patient safety and treatment quality. Its national rollout has established a unique, sector-wide system for incident analysis and continuous improvement, supported by the PRISMA methodology and the shared database. It includes:

• joint incident analysis and improvement measures
  A concrete example of PRISMA-RT’s strength is the joint analysis of alert issues. This concerns incidents related to the readability of technical notifications. National collaboration quickly revealed that similar risks existed at other institutions. This led to the adjustment of work protocols, which were published in the Green Journal [2];
• training days and inter-rater reliability
  PRISMA-RT organises annual training days that are focused on practical examples. During these days, incidents are discussed, analyses compared, and best practices shared. Analysts are trained and tested for inter-rater reliability, ensuring high-quality analyses. This ensures a uniform approach and a learning culture within the sector, and
•  benchmarking and transparency
  The national network enables institutions to compare their incident data. For example, one institution noticed that the number of incidents related to patient identification was higher than the national average. This comparison led to targeted improvement actions, such as additional training and the adjustment of identification procedures.

 

Expansion to Belgium

In Belgium, the PRISMA-RT methodology and the concept of national collaboration among radiotherapy departments were adopted in 2010. As part of the Belgian Cancer Plan, quality improvement projects were launched, including:

• the creation of a centralised database of radiotherapy safety events
  Inspired by the Dutch experience, Belgium decided to encourage all radiotherapy departments to adopt the PRISMA methodology to analyse safety events. A central database was created to collect and classify all identified root causes, and this database enabled sector-wide registration and analysis of incidents. This approach made it possible to detect trends and share lessons learned across the entire network.
• the creation of a national platform for dosimetry audits

A coordinated platform was established so that dosimetry audits could be organised and standardised at the national level. This is also known as the BeldArt project [3]; and

 

• financial support to appoint a dedicated quality manager in each radiotherapy department
  These managers are responsible for setting up quality management systems, following up on incidents and preparing departments for the Belgian Quality Assurance Team for Radiation Oncology (B-QUATRO) clinical audits [4].

 

Like the Dutch PRISMA-RT philosophy, the Belgian approach encourages collaboration among centres, including through joint audits and sharing best practices.

 

Experiences with the National Rollouts of PRISMA-RT

Although the rollout of the PRISMA-RT network differed between these countries—The Netherlands took a bottom-up approach while Belgium used top-down—both strategies have led to significant improvements in risk management in radiotherapy departments.

1. Collaboration and Knowledge Sharing

The national rollouts of PRISMA-RT networks have led to intensive collaboration among radiotherapy institutions. By sharing incident reports and joint analysis of them using the PRISMA method, national databases have been created. These networks make it possible to identify and address trends and risks at the national level. Institutions keep each other informed of new developments and encourage each other to maintain a high level of expertise.

2. Uniformity and Benchmarking

The national implementations have standardised processes and enabled benchmarking. Incident data are coded and analysed in the same way, allowing institutions to compare their performances and to learn from each other. This has led to a culture of openness and transparency, with learning from incidents at its core.

3. Training and Professional Development

PRISMA-RT organises training days and provides an expert team to support institutions with questions. Analysts in the Netherlands are continuously trained and tested for inter-rater reliability in order to ensure that the quality of analyses remains high. This contributes to a professional and uniform approach to incident analysis.

4. Practical Implementation

The rollouts are technically and organisationally feasible. The networks are integrated with existing systems, and initial feedback from users has generally been positive. National collaboration is supported through mailing lists, newsletters, and joint projects.
 

Benefits of PRISMA-RT

In both countries, the use of a common near-incident and incident analysis methodology and the collaborations that arise from it have led to a number of benefits. These benefits are visible in improved collaboration, standardisation, expertise, and transparency.

• Improved patient safety: systematic analysis of incidents reveals their underlying causes, enabling targeted improvement measures.
• Enhanced learning culture: open exchange of data on incidents and solutions fosters a culture of learning and improvement.
• Efficiency and standardisation: national agreements and the use of uniform methodology prevent duplication of work and allow institutions to learn from each other quickly.
• Support and expertise: the organisation of training days, expert teams, and national meetings ensures ongoing professional development.
• Benchmarking and transparency: institutions can compare their performances and work together on sector-wide improvements.
   

Connection and promotion of ROSEIS

At the ESTRO Congress 2025 in Vienna, Austria, the ESTRO radiation oncology safety and quality committee launched the Radiation Oncology Safety Education and Information System ( ROSEIS). The system can be accessed at https://roseis.estro.org/.

ROSEIS was created to enable the sharing of information on incidents and near-incidents in a safe environment in order to increase learning and improve the quality and safety of practice across European centres. The launch of ROSEIS was covered in a previous ESTRO newsletter, and the article can be seen through this link:

https://www.estro.org/About/Newsroom/Newsletter/ROSQ/Introducing-ROSEIS-Advancing-Safety-and-Quality-in

 

Conclusion

The national rollout of PRISMA-RT in the Netherlands has led to tangible improvements in patient safety and quality culture. The expansion to Belgium shows that this approach can be transferred internationally, with similar benefits for the radiotherapy sector. Through collaboration, transparency, and continuous training using practical examples of incident analysis, patient care can and is becoming increasingly safer and better.

By learning from national collaborations, the ROSEIS will create greater opportunities for shared learning and increased safety awareness among healthcare professionals, while also reassuring patients and the public that radiotherapy professionals actively work to improve the safety and quality of care.

Petra Reijnders-Thijssen, MA
Chair, ROSQ Committee
Course Director, ESTRO Risk Management Course
Manager Quality and Safety, Maastro
Maastricht, The Netherlands
petra.reijnders@maastro.nl

Aude Vaandering, PhD
Member, ROSQ Committee
Faculty, ESTRO Risk Management Course
Radiotherapy Quality Manager
Radiation Oncology Department
Cliniques Universitaires St Luc
Brussels, Belgium

 

References

[1] Snijders, C., van der Schaaf, T. W., Klip, H., van Lingen, R. a, Fetter, W. P. F., & Molendijk, A. (2009). Feasibility and reliability of PRISMA-medical for specialty-based incident analysis. Quality & Safety in Health Care, 18(6), 486–491. https://doi.org/10.1136/qshc.2008.028068

[2] Reijnders-Thijssen P, Geerts D, van Elmpt W, Pawlicki T, Wallis A, Coffey M. Prevalence of software alerts in radiotherapy. Tech Innov Patient Support Radiat Oncol. 2020 Jun 12;14:32-35. doi: 10.1016/j.tipsro.2020.04.002. PMID: 32566767; PMCID: PMC7296428.

[3] Yalvac, B., Reulens, N. R., Schroeyers, W., Schreurs, S., & Reniers, B. (2019). BELdART: A Belgian dosimetry audit programme in radiotherapy based on alanine/EPR and radiochromic film dosimetry. SSDL Newsletter, 70. https://uhdspace.uhasselt.be/dspace/bitstream/1942/28660/2/p 24-26 van ssdl-70.pdf

[4] Vaandering, A., Lievens, Y., & P Scalliet, P. (2020). Feasibility and impact of national peer-reviewed clinical audits in radiotherapy departments. Radiotherapy and Oncology, 144, 218–223. https://doi.org/10.1016/j.radonc.2020.01.012