Document Detail


Trend analysis of radiation therapy incidents over seven years.
MedLine Citation:
PMID:  20542343     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
PURPOSE: To examine incident rates in external beam radiation therapy (RT) as significant changes in technology were introduced.
MATERIALS AND METHODS: From 2001 to 2007, several technological and practice enhancements were made. All treatment incident reports, including near misses (from 2004), were classified, under a research ethics board approval, according to type (prescription or geometry), cause (location, documentation, non-compliance, laterality, prescribed change, human error, planning/dosimetry, software/hardware malfunction, and accessory), and clinical impact (none, minor, moderate, and severe). Trend analysis was performed retrospectively.
RESULTS: One thousand and sixty three reports were analyzed. The average incident rate per 100 RT course was 1.7+/-0.4; excluding near misses, this rate fell to 1.4+/-0.3. Both rates showed a downward trend. The occurrence of events due to treatment accessories (0.75-0.28), prescribed changes to treatment parameters (0.17-0.03), and location (0.41-0.17) have decreased, while documentation-related incidents have risen (0.03-0.37). The proportion of incidents is highest at the planning and treatment stages.
CONCLUSION: Our analysis has shown that while technological and process enhancements can reduce certain error pathways, others can be created. Trends in incident rates have been assessed, indicating robustness of our practice in view of these changes.
Authors:
Jean-Pierre Bissonnette; Gaylene Medlam
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Publication Detail:
Type:  Evaluation Studies; Journal Article     Date:  2010-06-11
Journal Detail:
Title:  Radiotherapy and oncology : journal of the European Society for Therapeutic Radiology and Oncology     Volume:  96     ISSN:  1879-0887     ISO Abbreviation:  Radiother Oncol     Publication Date:  2010 Jul 
Date Detail:
Created Date:  2010-07-08     Completed Date:  2010-12-02     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  8407192     Medline TA:  Radiother Oncol     Country:  Ireland    
Other Details:
Languages:  eng     Pagination:  139-44     Citation Subset:  IM    
Copyright Information:
Copyright 2010 Elsevier Ireland Ltd. All rights reserved.
Affiliation:
Radiation Medicine Program, Princess Margaret Hospital, Toronto, Ontario, Canada. jean-pierre.bissonnette@rmp.uhn.on.ca
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MeSH Terms
Descriptor/Qualifier:
Canada
Databases, Factual
Humans
Medical Errors / statistics & numerical data*
Quality Control
Radiation Injuries / epidemiology*,  prevention & control
Radiation Oncology / methods,  trends*
Radiotherapy Dosage
Safety Management
Time Factors

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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