Trend analysis of radiation therapy incidents over seven years
| Autor: | Gaylene Medlam, Jean-Pierre Bissonnette |
|---|---|
| Rok vydání: | 2010 |
| Předmět: |
Quality Control
Canada Safety Management medicine.medical_specialty Time Factors Databases Factual government.form_of_government medicine.medical_treatment Human error Treatment parameters Near miss Patient safety Humans Medicine Radiology Nuclear Medicine and imaging Medical prescription Radiation Injuries Medical Errors business.industry Radiotherapy Dosage Hematology Radiation therapy Trend analysis Oncology Emergency medicine Radiation Oncology government business Incident report |
| Zdroj: | Radiotherapy and Oncology. 96:139-144 |
| ISSN: | 0167-8140 |
| DOI: | 10.1016/j.radonc.2010.05.002 |
| Popis: | 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. |
| Databáze: | OpenAIRE |
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