Radiation Oncology Safety Information System (ROSIS) - Profiles of participants and the first 1074 incident reports

Radiotherapy and Oncology

Volumn 97, Issue 3, 2010, Pages 601-607

  Cunningham, Joanne ^a   Coffey, Mary ^a   Knöös, Tommy ^b   Holmberg, Ola ^c  

^a ST JAMES S HOSPITAL   (Ireland)

^b LUND UNIVERSITY HOSPITAL   (Sweden)

^c Division of Radiation Transport and Waste Safety   (Austria)

Author keywords

Incident; Learning; Patient safety; Reporting; Risk; Risk management

Indexed keywords

ARTICLE; BRACHYTHERAPY; CANCER RADIOTHERAPY; EXTERNAL BEAM RADIOTHERAPY; INFORMATION PROCESSING; INFORMATION SYSTEM; LEARNING; PATIENT SAFETY; PRIORITY JOURNAL; QUALITY CONTROL; RISK MANAGEMENT;

BRACHYTHERAPY; DATABASES, FACTUAL; HUMANS; INTERNATIONAL COOPERATION; INTERNET; MEDICAL ERRORS; PARTICLE ACCELERATORS; QUALITY ASSURANCE, HEALTH CARE; RADIATION ONCOLOGY; RADIOTHERAPY, HIGH-ENERGY; RISK MANAGEMENT; SAFETY MANAGEMENT;

EID: 78651500187     PISSN: 01678140     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.radonc.2010.10.023     Document Type: Article

References (51)

1. World Health Organisation. Radiotherapy Risk Profile: technical manual. Geneva: WHO; 2009.
2. J. Valentin Prevention of high-dose-rate brachytherapy accidents. ICRP Publication 97 Ann ICRP 35 2005 1 51
3. Thomadsen B. Lessons to be learned from brachytherapy misadministrations. In: Enderle JD, editor. Annual international conference of the IEEE engineering in medicine and biology - proceedings, Chicago, IL; 2000. p. 2945-49.
4. Prevention of accidental exposures to patients undergoing radiation therapy. A report of the international commission on radiological protection. Ann ICRP 2000;30:7-70.
5. B. Furlow Radiotherapy errors spark investigations and reform The Lancet Oncol 10 2009 11 12
6. International Atomic Energy Agency. Lessons learned from accidental exposures in radiotherapy. Safety Reports Series 17. Vienna, Austria: IAEA; 2000.
7. J. DeRosier, E. Stalhandske, J.P. Bagian, and T. Nudell Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective risk analysis system Jt Comm J Qual Improv 28 2002 248 267
8. D.A. Marx, and A.D. Slonim Assessing patient safety risk before the injury occurs: an introduction to sociotechnical probabilistic risk modelling in health care Qual Saf Health Care 12 2003
9. P. Trucco, and M. Cavallin A quantitative approach to clinical risk assessment: the CREA method Saf Sci 44 2006
10. Chappell L. Using voluntary incident reports for human factors evaluations. In: Johnston N, McDonald N, Fuller R, editors. Aviation psychology in practice: Avebury Technical; 1994.
11. L. Wright, and T.V.D. Schaaf Accident versus near miss causation: A critical review of the literature, an empirical test in the UK railway domain, and their implications for other sectors J Hazard Mater 111 2004 105 110
12. P. Barach, and S.D. Small Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems Br Med J 320 2000 759 763
13. W.B. Runciman, J.A.H. Williamson, A. Deakin, K.A. Benveniste, K. Bannon, and P.D. Hibbert An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification Qual Saf Health Care 2006 15
14. L.L. Leape Reporting of adverse events N Engl J Med 347 2002 1633 1638
15. E.U. Ekaette, R.C. Lee, D.L. Cooke, K.L. Kelly, and P.B. Dunscombe Risk analysis in radiation treatment: application of a new taxonomic structure Radiother Oncol 80 2006 282 287
16. M.V. Williams Improving patient safety in radiotherapy by learning from near misses, incidents and errors Br J Radiol 80 2007 297 301
17. M.V. Williams Radiotherapy near misses, incidents and errors: Radiotherapy incident at Glasgow Clin Oncol 19 2007 1 3
18. The Royal College of Radiologists. Towards Safer Radiotherapy. The Royal College of Radiologists, BCFO(08)1. London; 2008.
19. K. Tylko, and M. Blennerhassett How the NHS could better protect the safety of radiotherapy patients Health Care Risk Rep 12 2006 18 19
20. O. Holmberg Accident prevention in radiotherapy Biomed Imaging Interv J 3 2007 e27
21. International Atomic Energy Agency. International basic safety standards for protection against ionizing radiation and for the safety of radiation sources. Vienna: IAEA; 1996.
22. United Nations. Sources and Effects of Ionizing Radiation. United Nations Scientific Committee on the Effects of Atomic Radiation. UNSCEAR 2008 report to the general assembly, with scientific annexes, New York; 2010.
23. S.M. Bentzen, G. Heeren, and B. Cottier Towards evidence-based guidelines for radiotherapy infrastructure and staffing needs in Europe: the ESTRO QUARTS project Radiother Oncol 75 2005 355 365
24. G. Leunens, J. Verstraete, W. Van den Bogaert, J. Van Dam, A. Dutreix, and E. Van der Schueren 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
25. H.I. Amols New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology Health Phys 95 2008 658 665
26. B.J. Slotman, B. Cottier, S.M. Bentzen, G. Heeren, Y. Lievens, and W. van den Bogaert Overview of national guidelines for infrastructure and staffing of radiotherapy. ESTRO-QUARTS: Work package 1 Radiother Oncol 75 2005 349.E341 349.E346
27. D. Thwaites, P. Scalliet, J. Leer, and J. Overgaard 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'. 1995 Radiother Oncol 35 1995 61 73
28. Y. Watanabe Lessons from incidents and accidents in radiotherapy Nippon Hoshasen Gijutsu Gakkai Zasshi 62 2006 657 660
29. Institute of Physics and Engineering in Medicine. Physics aspects of quality control in radiotherapy. Rep. 81, York: IPEM; 1999.
30. G.J. Kutcher, and Q.A. Comprehensive For radiation oncology: Report of AAPM Radiation Therapy Committee Task Group 40 Med Phys 21 1994 581 618
31. O. Holmberg, and B. McClean Preventing treatment errors in radiotherapy by identifying and evaluating near misses and actual incidents J Radiother Pract 3 2002 13
32. R. Calandrino, G.M. Cattaneo, C. Fiorino, B. Longobardi, P. Mangili, and P. Signorotto Detection of systematic errors in external radiotherapy before treatment delivery Radiother Oncol 45 1997 271 274
33. L. Duggan, T. Kron, S. Howlett, A. Skov, and P. O'Brien An independent check of treatment plan, prescription and dose calculation as a QA procedure Radiother Oncol 42 1997 297 301
34. M.C. Valli, M. Prina, and A. Bossi Evaluation of most frequent errors in daily compilation and use of a radiation treatment chart Radiother Oncol 32 1994 87 89
35. R. Calandrino, G.M. Cattaneo, A. Del Vecchio, C. Morino, B. Longobardi, and P. Signorotto Human errors in the calculation of monitor units in clinical radiotherapy practice Radiother Oncol 28 1993 86 88
36. C. Fiorino, D. Corletto, and P. Mangili Quality assurance by systematic in vivo dosimetry: results on a large cohort of patients Radiother Oncol 56 2000 85 95
37. A. Noel, P. Aletti, P. Bey, and L. Malissard Detection of errors in individual patients in radiotherapy by systematic in vivo dosimetry Radiother Oncol 34 1995 144 151
38. J.H. Lanson, M. Essers, G.J. Meijer, A.W.H. Minken, G.J. Uiterwaal, and B.J. Mijnheer In vivo dosimetry during conformal radiotherapy: requirements for and findings of a routine procedure Radiother Oncol 52 1999 51 59
39. A.G. Morganti, F. Deodato, and S. Zizzari Complexity index (COMIX) and not type of treatment predicts undetected errors in radiotherapy planning and delivery Radiother Oncol 2008
40. M.V. Williams, and A. McKenzie Can we afford not to implement in vivo dosimetry? Br J Radiol 81 2008 681 684
41. A.J. Munro Hidden danger, obvious opportunity: error and risk in the management of cancer Br J Radiol 80 2007 955 966
42. A. McKenzie, G. Briggs, and R. Buchanan Balancing Costs and Benefits of Checking in Radiotherapy. Report 92 2006 IPEM York, UK
43. Thwaites D. A minimum quality assurance programme of the treatment unit. In: Radiation dose in radiotherapy from prescription to delivery, IAEA TECDOC-734, Vienna: IAEA; 1997. p. 201-8.
44. T.P. Shakespeare, M.F. Back, J.J. Lu, K.M. Lee, and R.K. Mukherjee External audit of clinical practice and medical decision making in a new Asian oncology center: results and implications for both developing and developed nations Int J Radiat Oncol Biol Phys 64 2006 941 947
45. International Nuclear Safety Advisory Group. Safety culture. Safety series no. 75-INSAG-4. Vienna: IAEA; 1991.
46. International Commission on Radiological Protection. ICRP publication 112. Preventing accidental exposures from new external beam radiation therapy technologies. Ann ICRP 2009;39:3-5.
47. T.K. Yeung, K. Bortolotto, S. Cosby, M. Hoar, and E. Lederer Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period Radiother Oncol 74 2005 283 291
48. J. Cunningham, M. Coffey, O. Holmberg, and T. Knöös ROSIS (Radiation Oncology Safety Information System) Recognising risk, enhancing safety Radiother Oncol 73 2004 S220
49. N. Stanhope, M. Crowley-Murphy, C. Vincent, A.M. O'Connor, and S.E. Taylor-Adams An evaluation of adverse incident reporting J Eval Clin Pract 5 1999 5 12
50. B.A. Fraass, K.L. Lash, G.M. Matrone, S.K. Volkman, D.L. McShan, and M.L. Kessler The impact of treatment complexity and computer-control delivery technology on treatment delivery errors Int J Radiat Oncol Biol Phys 42 1998 651 659
51. N. Barthelemy-Brichant, J. Sabatier, W. Dew, A. Albert, and J.M. Deneufbourg Evaluation of frequency and type of errors detected by a computerized record and verify system during radiation treatment Radiother Oncol 53 1999 149 154