Trend analysis of radiation therapy incidents over seven years

Radiotherapy and Oncology

Volumn 96, Issue 1, 2010, Pages 139-144

  Bissonnette, Jean Pierre ^a   Medlam, Gaylene ^a  

^a PRINCESS MARGARET HOSPITAL   (Canada)

Author keywords

Medical errors; Patient safety; Quality assurance; Quality improvement

Indexed keywords

ARTICLE; COMPUTER; COMPUTER PROGRAM; DOSIMETRY; EXTERNAL BEAM RADIOTHERAPY; HUMAN; INCIDENT REPORT; INTENSITY MODULATED RADIATION THERAPY; MEDICAL ERROR; PATIENT SAFETY; PRESCRIPTION; PRIORITY JOURNAL; RADIOTHERAPY; RETROSPECTIVE STUDY; STEREOTACTIC BODY RADIATION THERAPY; TREATMENT PLANNING; UNITED STATES;

CANADA; DATABASES, FACTUAL; HUMANS; MEDICAL ERRORS; QUALITY CONTROL; RADIATION INJURIES; RADIATION ONCOLOGY; RADIOTHERAPY DOSAGE; SAFETY MANAGEMENT; TIME FACTORS;

EID: 77953962317     PISSN: 01678140     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.radonc.2010.05.002     Document Type: Article

References (32)

1. WHO Organization (WHO). Radiotherapy risk profile: technical manual. Geneva: WHO; 2009. Available from: http://www.who.int/patientsafety/activities/technical/radiotherapy/en/index.html [Accessed May 2010].
2. 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
3. Barthelemy-Brichant N., Sabatier J., Dewe W., Albert A., and Deneufbourg J.M. Evaluation of frequency and type of errors detected by a computerized record and verify system during radiation treatment. Radiother Oncol 53 (1999) 149-154
4. Huang G., Medlam G., Lee J., et al. Error in the delivery of radiation therapy: results of a quality assurance review. Int J Radiat Oncol Biol Phys 61 (2005) 1590-1595
5. Macklis R.M., Meier T., and Weinhous M.S. Error rates in clinical radiotherapy. J Clin Oncol 16 (1998) 551-556
6. Fraass B.A., Lash K.L., Matrone G.M., et al. The impact of treatment complexity and computer-control delivery technology on treatment delivery errors. Int J Radiat Oncol Biol Phys 42 (1998) 651-659
7. Klein E.E., Drzymala R.E., Purdy J.A., and Michalski J. Errors in radiation oncology: a study in pathways and dosimetric impact. J Appl Clin Med Phys 6 (2005) 81-94
8. 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
9. Morganti A.G., Deodato F., Zizzari S., et al. Complexity index (COMIX) and not type of treatment predicts undetected errors in radiotherapy planning and delivery. Radiother Oncol 89 (2008) 320-329
10. Cosset J.M., and Gourmelon P. Accidents in radiotherapy: historical account. Cancer Radiother 6 (2002) 166s-170s
11. Peiffert D., Simon J.M., and Eschwege F. Epinal radiotherapy accident: passed, present, future. Cancer Radiother 11 (2007) 309-312
12. Derreumaux S., Etard C., Huet C., et al. Lessons from recent accidents in radiation therapy in France. Radiat Prot Dosimetry 131 (2008) 130-135
13. Mayles W.P. The Glasgow incident - a physicist's reflections. Clin Oncol (R Coll Radiol) 19 (2007) 4-7
14. Williams M.V. Radiotherapy near misses, incidents and errors: radiotherapy incident at Glasgow. Clin Oncol (R Coll Radiol) 19 (2007) 1-3
15. Borras C. Overexposure of radiation therapy patients in Panama: problem recognition and follow-up measures. Rev Panam Salud Publica 20 (2006) 173-187
16. Israelski E.W., and Muto W.H. Human factors risk management as a way to improve medical device safety: a case study of the Therac 25 radiation therapy system. Jt Comm J Qual Saf 30 (2004) 689-695
17. Thongpraparn T., Chaudakshetrin P., and Buranapong P. Lesson learned from Co-60 accident in Thailand. Australas Phys Eng Sci Med 25 (2002) 172-174
18. Fraass B.A. QA issues for computer-controlled treatment delivery: this is not your old R/V system any more!. Int J Radiat Oncol Biol Phys 71 (2008) S98-S102
19. Patton G.A., Gaffney D.K., and Moeller J.H. Facilitation of radiotherapeutic error by computerized record and verify systems. Int J Radiat Oncol Biol Phys 56 (2003) 50-57
20. Fraass B.A. Errors in radiotherapy: motivation for development of new radiotherapy quality assurance paradigms. Int J Radiat Oncol Biol Phys 71 (2008) S162-S165
21. Palta J.R., Liu C., and Li J.G. Current external beam radiation therapy quality assurance guidance: does it meet the challenges of emerging image-guided technologies?. Int J Radiat Oncol Biol Phys 71 (2008) S13-S17
22. Reason J. Human error: models and management. BMJ 320 (2000) 768-770
23. Kutcher G.J., Coia L., Gillin M., et al. Comprehensive QA for radiation oncology: Report of the AAPM Radiation Therapy Committee Task Group 40. Med Phys 21 (1994) 581-618
24. Belletti S., Dutreix A., Garavaglia G., et al. Quality assurance in radiotherapy: the importance of medical physics staffing levels. Recommendations from an ESTRO/EFOMP joint task group. Radiother Oncol 41 (1996) 89-94
25. Cooke D, Dubetz M, Heshmati R, et al. A reference guide for learning from incidents in radiation treatment. HTA Initiative Series 2006; 22. Accessed at http://www.ihe.ca/documents/HTA-FR22.pdf [Accessed May 2010].
26. Williams M.V. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol 80 (2007) 297-301
27. Thomadsen B., and Lin S.W. Taxonometric guidance for developing quality assurance. Int J Radiat Oncol Biol Phys 71 (2008) S204-S209
28. Ekaette E.U., Lee R.C., Cooke D.L., Kelly K.L., and Dunscombe P.B. Risk analysis in radiation treatment: application of a new taxonomic structure. Radiother Oncol 80 (2006) 282-287
29. 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
30. Haynes A.B., Weiser T.G., Berry W.R., et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 360 (2009) 491-499
31. Logan T.J. Error prevention as developed in airlines. Int J Radiat Oncol Biol Phys 71 (2008) S178-S181
32. Thomadsen B., Lin S.W., Laemmrich P., et al. Analysis of treatment delivery errors in brachytherapy using formal risk analysis techniques. Int J Radiat Oncol Biol Phys 57 (2003) 1492-1508