Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period
Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period
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DOI：
10.1016/j.radonc.2004.12.003
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发表时间：
2005-03-01
影响因子：
5.7
通讯作者：
Lederer, E
中科院分区：
文献类型：
--
作者：
Yeung, TK;Bortolotto, K;Lederer, E
背景和目的：建立一个事件报告系统，以（1）记录和分类事件，（2）评估事件对患者剂量误差的影响，（3）评估东北安大略地区癌症中心（NEORCC）放射治疗计划实施的质量保证检查计划的有效性。“事件”定义为导致或如果未被发现则会导致接受放射治疗的患者剂量错误的事件或一系列事件。根据错误来源、发现阶段和剂量错误对1992年11月至2002年12月期间报告的事件进行了分析。结果：1992年11月至2002年12月期间，有13385名患者在NEORCC接受了放射治疗。在此期间，报告了624起“事件”。错误来源：大部分事故（42.1%）与“文件错误有关，而其中大部分可归因于”资料传送错误或“沟通不足。“患者设置错误”占事件的40.4%，其中约一半与屏蔽有关。“治疗计划”错误占事件的13.0%。发现阶段：由另一名剂量师/物理学家进行的独立检查以及患者首次设置和端口胶片期间的检查在检测记录错误和治疗计划错误方面是有效的。射野成像（Siemens Beamview（TM））的使用使我们能够检测和纠正患者设置中超过85%的报告屏蔽错误。剂量错误：40%的事件是在首次治疗前发现的，患者没有剂量错误。97.9%的事件剂量误差<5%。结论：放射治疗过程中，人为误差存在于放射治疗的各个阶段。如果不进行校正，这些可能导致患者的大量剂量错误。实施质量保证检查程序可以大大减少这些人为错误，但永远不会完全消除它们。(c)2004爱思唯尔爱尔兰有限公司保留所有权利。
Background and purpose: To establish an incident reporting system to (1) record and classify incidents, (2) assess the impact of incidents on patients in terms of dose errors, and (3) evaluate the effectiveness of the quality assurance checking program implemented at the Radiation Treatment Program at the Northeastern Ontario Regional Cancer Centre (NEORCC).Materials and methods: An 'incident' is defined as an event or a series of events that has led to, or would have led to if undiscovered, dose errors to a patient undergoing radiation therapy treatment. The incidents reported between November 1992 and December 2002 were analyzed according to their source of error, stage of discovery and dose errors.Results: Between November 1992 and December 2002, 13385 patients have undergone radiation treatment at the NEORCC. Over this period of time, 624 'incidents' were reported. Source of error: the majority of the incidents (42.1%) were related to errors in 'documentation' and most of these could be attributed to 'error in data transfer' or 'inadequate communication'. 'Patient set-up error' accounted for 40.4% of the incidents and about half of these errors were related to shielding. Errors in 'treatment planning' accounted for 13.0% of the incidents. Stage of discovery: independent checks by another dosimetrist/physicist and checking during patient first set-up and port film were effective in detecting documentation errors and errors in treatment planning. The use of portal imaging (Siemens Beamview (TM)) has enabled us to detect and correct for more than 85% of reported shielding errors in patient set-up. Dose errors: 40% of the incidents were discovered before the first treatment with no dose error to patients. Overall 97.9% of the incidents had dose error of < 5%.Conclusions: Human errors occur during the various stages of the complex process of radiation therapy. If uncorrected, these could lead to substantial dose errors to patients. The implementation of a quality assurance checking program can substantially reduce these human errors but never totally eliminate them. (c) 2004 Elsevier Ireland Ltd. All rights reserved.