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Volumn 93, Issue 3, 2009, Pages 609-617

Unintended exposure in radiotherapy: Identification of prominent causes

Author keywords

Contributing factors; Initiating events; Prominent causes; Radiotherapy; Unintended exposures

Indexed keywords

ARTICLE; CALIBRATION; CANCER RADIOTHERAPY; DOSIMETRY; EQUIPMENT; MEDICAL PRACTICE; MORBIDITY; PRIORITY JOURNAL; RADIATION EXPOSURE; RADIATION SAFETY;

EID: 70449641091     PISSN: 01678140     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.radonc.2009.08.044     Document Type: Article
Times cited : (30)

References (42)
  • 2
    • 0003639056 scopus 로고
    • Determination of absorbed dose in a patient irradiated by beams of X- or gamma-rays in radiotherapy procedures
    • International Commission on Radiation Units and Measurements, International Commission on Radiation Units and Measurement, Bethesda, MD;
    • International Commission on Radiation Units and Measurements. Determination of absorbed dose in a patient irradiated by beams of X- or gamma-rays in radiotherapy procedures. ICRU Report 24, International Commission on Radiation Units and Measurement, Bethesda, MD; 1976.
    • (1976) ICRU Report , vol.24
  • 3
    • 70449654342 scopus 로고
    • Quality management and quality assurance standards: Part I
    • International Standards Organisation, ISO, Geneva;
    • International Standards Organisation. Quality management and quality assurance standards: Part I. Guidelines for selection and use, ISO 9000, ISO, Geneva; 1994.
    • (1994) Guidelines for selection and use, ISO 9000
  • 4
    • 0004191346 scopus 로고
    • World Health Organisation, WHO, Geneva;
    • World Health Organisation. Quality assurance in radiotherapy. WHO, Geneva; 1988.
    • (1988) Quality assurance in radiotherapy
  • 5
    • 0029045088 scopus 로고
    • Quality assurance in radiotherapy. (European Society for Therapeutic Radiology and Oncology. Advisory Report to the Commission of the European Union for the 'Europe Against Cancer Programme')
    • Thwaites D.I., Scalliet P., Leer J.W., and Overgaard J. Quality assurance in radiotherapy. (European Society for Therapeutic Radiology and Oncology. Advisory Report to the Commission of the European Union for the 'Europe Against Cancer Programme'). Radiother Oncol 35 (1995) 61-73
    • (1995) Radiother Oncol , vol.35 , pp. 61-73
    • Thwaites, D.I.1    Scalliet, P.2    Leer, J.W.3    Overgaard, J.4
  • 6
    • 70449681625 scopus 로고    scopus 로고
    • Leer JW, McKenzie AL, Scalliet P, Thwaites DI. Practical guidelines for the implementation of a quality system in radiotherapy (European Society for Therapeutic Radiology and Oncology. A project of the ESTRO Quality Assurance Committee sponsored by 'Europe against Cancer'). Physics for Clinical Radiotherapy Booklet No. 4, ESTRO, Brussels; 1998.
    • Leer JW, McKenzie AL, Scalliet P, Thwaites DI. Practical guidelines for the implementation of a quality system in radiotherapy (European Society for Therapeutic Radiology and Oncology. A project of the ESTRO Quality Assurance Committee sponsored by 'Europe against Cancer'). Physics for Clinical Radiotherapy Booklet No. 4, ESTRO, Brussels; 1998.
  • 7
    • 52649105689 scopus 로고    scopus 로고
    • International Atomic Energy Agency, IAEA-TECDOC, IAEA, Vienna;
    • International Atomic Energy Agency. Quality assurance in radiotherapy. IAEA-TECDOC 989, IAEA, Vienna; 1997.
    • (1997) Quality assurance in radiotherapy , pp. 989
  • 8
    • 0028230872 scopus 로고
    • Comprehensive QA for radiation oncology. Report of AAPM Task Group 40
    • American Association of Physicists in Medicine
    • American Association of Physicists in Medicine. Comprehensive QA for radiation oncology. Report of AAPM Task Group 40. Med Phys 1994;21:581-618.
    • (1994) Med Phys , vol.21 , pp. 581-618
  • 9
    • 0033291944 scopus 로고    scopus 로고
    • Clinical Oncology Information Network. Guidelines for external beam radiotherapy
    • Clinical Oncology Information Network. Guidelines for external beam radiotherapy. Royal College of Radiologists. Clin Oncol 1999;11:S135-72.
    • (1999) Royal College of Radiologists. Clin Oncol , vol.11
  • 10
    • 70449681623 scopus 로고
    • International Electrotechnical Commission. Medical electrical equipment-medical electron accelerators: Functional performance characteristics
    • IEC 976, IEC, Geneva;
    • International Electrotechnical Commission. Medical electrical equipment-medical electron accelerators: functional performance characteristics, IEC 976, IEC, Geneva; 1989.
    • (1989)
  • 11
    • 70449683923 scopus 로고    scopus 로고
    • Physics aspects of quality control in radiotherapy
    • Institute of Physics and Engineering in Medicine, Report 81. York, United Kingdom: IPEM;
    • Institute of Physics and Engineering in Medicine. Physics aspects of quality control in radiotherapy. Report 81. York, United Kingdom: IPEM; 1998.
    • (1998)
  • 13
    • 31144456088 scopus 로고    scopus 로고
    • The EQUAL-ESTRO audit on geometric reconstruction techniques in brachytherapy
    • Roue A., Ferreira I.H., Dam J.V., Svensson H., and Venselaar J.L.M. The EQUAL-ESTRO audit on geometric reconstruction techniques in brachytherapy. Radiother Oncol 78 (2006) 78-83
    • (2006) Radiother Oncol , vol.78 , pp. 78-83
    • Roue, A.1    Ferreira, I.H.2    Dam, J.V.3    Svensson, H.4    Venselaar, J.L.M.5
  • 14
    • 0242321246 scopus 로고    scopus 로고
    • The IAEA/WHO TLD postal dose quality audits for radiotherapy: a perspective of dosimetry practices at hospitals in developing countries
    • Izewska J., Andreo P., Vatnitsky S., and Shortt K.R. The IAEA/WHO TLD postal dose quality audits for radiotherapy: a perspective of dosimetry practices at hospitals in developing countries. Radiother Oncol 69 (2003) 91-97
    • (2003) Radiother Oncol , vol.69 , pp. 91-97
    • Izewska, J.1    Andreo, P.2    Vatnitsky, S.3    Shortt, K.R.4
  • 15
    • 0031444593 scopus 로고    scopus 로고
    • A dosimetric intercomparison of electron beams in UK radiotherapy centres
    • Nisbet A., and Thwaites D.I. A dosimetric intercomparison of electron beams in UK radiotherapy centres. Phys Med Biol 42 (1997) 2393-2409
    • (1997) Phys Med Biol , vol.42 , pp. 2393-2409
    • Nisbet, A.1    Thwaites, D.I.2
  • 16
    • 0028206602 scopus 로고
    • The development of an interdepartmental audit as part of a physics quality assurance programme for external beam therapy
    • Bonnett D.E., Mills J.A., Aukett R.J., and Martin-Smith P. The development of an interdepartmental audit as part of a physics quality assurance programme for external beam therapy. Br J Radiol 67 (1994) 275-282
    • (1994) Br J Radiol , vol.67 , pp. 275-282
    • Bonnett, D.E.1    Mills, J.A.2    Aukett, R.J.3    Martin-Smith, P.4
  • 17
    • 0004329073 scopus 로고    scopus 로고
    • International basic safety standards for protection against ionising radiation and for the safety of radiation sources
    • Food and Agriculture Organisation of the United Nations, International Atomic Energy Agency, International Labour Organisation, OECD Nuclear Energy Agency, Pan American Health Organisation, World Health Organisation, IAEA, Vienna;
    • Food and Agriculture Organisation of the United Nations, International Atomic Energy Agency, International Labour Organisation, OECD Nuclear Energy Agency, Pan American Health Organisation, World Health Organisation. International basic safety standards for protection against ionising radiation and for the safety of radiation sources. IAEA Safety Series 115, IAEA, Vienna; 1996.
    • (1996) IAEA Safety Series , vol.115
  • 18
    • 70449689859 scopus 로고    scopus 로고
    • Radiation protection and the safety of radiation sources
    • International Atomic Energy Agency, IAEA, Vienna;
    • International Atomic Energy Agency. Radiation protection and the safety of radiation sources. IAEA Safety Series 120, IAEA, Vienna; 1996.
    • (1996) IAEA Safety Series , vol.120
  • 19
    • 70449665671 scopus 로고    scopus 로고
    • International Atomic Energy Agency. Radiological protection for medical exposure to ionizing radiation. IAEA Safety Standards Series RS-G-1.5, IAEA, Vienna; 2002.
    • International Atomic Energy Agency. Radiological protection for medical exposure to ionizing radiation. IAEA Safety Standards Series RS-G-1.5, IAEA, Vienna; 2002.
  • 20
    • 70449692848 scopus 로고    scopus 로고
    • International Atomic Energy Agency. Regulatory control of radiation sources. IAEA Safety Standards Series GS-G-1.5, IAEA, Vienna; 2004.
    • International Atomic Energy Agency. Regulatory control of radiation sources. IAEA Safety Standards Series GS-G-1.5, IAEA, Vienna; 2004.
  • 22
    • 76749162536 scopus 로고    scopus 로고
    • Applying radiation safety standards in radiotherapy
    • International Atomic Energy Agency, IAEA, Vienna;
    • International Atomic Energy Agency. Applying radiation safety standards in radiotherapy. IAEA Safety Reports Series 38, IAEA, Vienna; 2006.
    • (2006) IAEA Safety Reports Series , vol.38
  • 23
    • 77954770741 scopus 로고    scopus 로고
    • Radiation protection in the design of radiotherapy facilities
    • International Atomic Energy Agency, IAEA, Vienna;
    • International Atomic Energy Agency. Radiation protection in the design of radiotherapy facilities. IAEA Safety Reports Series 47, IAEA, Vienna; 2006.
    • (2006) IAEA Safety Reports Series , vol.47
  • 24
    • 0003730190 scopus 로고    scopus 로고
    • Lessons learned from accidental exposures in radiotherapy
    • International Atomic Energy Agency, IAEA, Vienna;
    • International Atomic Energy Agency. Lessons learned from accidental exposures in radiotherapy. IAEA Safety Reports Series 17, IAEA, Vienna; 2000.
    • (2000) IAEA Safety Reports Series , vol.17
  • 25
  • 26
    • 0004074489 scopus 로고
    • International Atomic Energy Agency, IAEA, Vienna;
    • International Atomic Energy Agency. The radiological accident in Goiânia. IAEA, Vienna; 1988.
    • (1988) The radiological accident in Goiânia
  • 28
    • 0004155592 scopus 로고    scopus 로고
    • International Atomic Energy Agency, IAEA, Vienna;
    • International Atomic Energy Agency. The radiological accident in Istanbul. IAEA, Vienna; 2000.
    • (2000) The radiological accident in Istanbul
  • 30
  • 32
    • 70449650063 scopus 로고    scopus 로고
    • Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre Glasgow in January 2006. Report of the investigation by Inspector appointed by the Scottish Ministers for the Ionizing Radiation (Medical Exposures) Regulations; 2000. Available from
    • Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre Glasgow in January 2006. Report of the investigation by Inspector appointed by the Scottish Ministers for the Ionizing Radiation (Medical Exposures) Regulations; 2000. Available from: http://www.scotland.gov.uk/Publications/2006/10/27084909/0.
  • 33
    • 70449695786 scopus 로고    scopus 로고
    • Gamma knife treatment to wrong side of brain
    • United States Nuclear Regulatory Commission, 43746; 2007
    • United States Nuclear Regulatory Commission. Gamma knife treatment to wrong side of brain. Event Notification Report 43746; 2007.
    • Event Notification Report
  • 34
    • 70449648503 scopus 로고    scopus 로고
    • Nucléaire. Cancer radiotherapy: A justified practice but one that demands considerable stringency on the part of the operators and vigilant supervision by ANS
    • Annual Report. ANS; 2006
    • Autorité de Sûreté Nucléaire. Cancer radiotherapy: a justified practice but one that demands considerable stringency on the part of the operators and vigilant supervision by ANS. Annual Report. ANS; 2006.
    • Autorité de Sûreté1
  • 36
    • 85007972819 scopus 로고    scopus 로고
    • Preventing treatment errors in radiotherapy by identifying and evaluating near-misses and actual incidents
    • Holmberg O., and McClean B. Preventing treatment errors in radiotherapy by identifying and evaluating near-misses and actual incidents. J Radiother Pract 3 (2002) 13-25
    • (2002) J Radiother Pract , vol.3 , pp. 13-25
    • Holmberg, O.1    McClean, B.2
  • 37
    • 34548152917 scopus 로고    scopus 로고
    • Improving patient safety in radiotherapy by learning from near-misses, incidents and errors
    • Williams M.V. Improving patient safety in radiotherapy by learning from near-misses, incidents and errors. Br J Radiol 80 (2007) 297-301
    • (2007) Br J Radiol , vol.80 , pp. 297-301
    • Williams, M.V.1
  • 38
    • 66949129631 scopus 로고    scopus 로고
    • An international review of patient safety measures in radiotherapy practice
    • Shafiq J., Barton M., Noble D., Lemer C., and Donaldson L.J. An international review of patient safety measures in radiotherapy practice. Radiother Oncol 92 (2009) 15-21
    • (2009) Radiother Oncol , vol.92 , pp. 15-21
    • Shafiq, J.1    Barton, M.2    Noble, D.3    Lemer, C.4    Donaldson, L.J.5
  • 39
    • 0034681861 scopus 로고    scopus 로고
    • Reporting and preventing medical mishaps: lessons from non-medical near-miss reporting systems
    • Barach P., and Small S.D. Reporting and preventing medical mishaps: lessons from non-medical near-miss reporting systems. Br Med J 320 (2000) 759-763
    • (2000) Br Med J , vol.320 , pp. 759-763
    • Barach, P.1    Small, S.D.2
  • 40
    • 70449676410 scopus 로고    scopus 로고
    • Terminology used in nuclear safety and radiation protection
    • International Atomic Energy Agency, 2007 edition, IAEA, Vienna;, Available from
    • International Atomic Energy Agency. Terminology used in nuclear safety and radiation protection. IAEA Safety Glossary 2007 edition, IAEA, Vienna; 2007. Available from http://www-pub.iaea.org/MTCD/publications/PDF/Pub1290_web.pdf.
    • (2007) IAEA Safety Glossary
  • 41
    • 0026587135 scopus 로고
    • Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: "garbage in, garbage out"
    • Leunens G., Verstraete J., Bogaert W., et al. Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: "garbage in, garbage out". Radiother Oncol 23 (1992) 217-222
    • (1992) Radiother Oncol , vol.23 , pp. 217-222
    • Leunens, G.1    Verstraete, J.2    Bogaert, W.3
  • 42
    • 14844290322 scopus 로고    scopus 로고
    • Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period
    • Yeung T.K., Bortolotto K., Cosby S., Hoar M., and Lederer E. Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period. Radiother Oncol 74 (2005) 283-291
    • (2005) Radiother Oncol , vol.74 , pp. 283-291
    • Yeung, T.K.1    Bortolotto, K.2    Cosby, S.3    Hoar, M.4    Lederer, E.5


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