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"Medical error" "radiation therapy"

M I Pylypenko, L L Stadnyk, M M Rygan, Ju M Skaleckyj, O Ju Shalopa
INTRODUCTION: Actuality of the problem of patient safety in oncoradiology in Ukraineis grounded. OBJECTIVE: assessment of the safety of patients who performed radiation therapy, and extent of medical and social consequences of erroneous actions of personnel in this area. MATERIAL AND METHODS: The results of international audit TLD (IAEA / WHO) quality during dosimetry procedures cobalt telehamma vehicles in Ukraine are investigated, as well as legal and regulatory framework providing for the safety of radiotherapy care, scientific publications on patient safety...
December 2015: Problemy Radiat︠s︡iĭnoï Medyt︠s︡yny Ta Radiobiolohiï
M M Arkans, T L Gieger, M W Nolan
Recent technical advancements in radiation therapy have allowed for improved targeting of tumours and sparing nearby normal tissues, while simultaneously decreasing the risk for medical errors by incorporating additional safety checks into electronic medical record keeping systems. The benefits of these new technologies, however, depends on their proper integration and use in the oncology clinic. Despite the advancement of technology for treatment delivery and medical record keeping, misadministration errors have a significant impact on patient care in veterinary oncology...
March 2017: Veterinary and Comparative Oncology
Steven G Sutlief
In radiation therapy, unlike most other applications involving radiation, the intention is to deliver high doses of radiation to diseased tissue, constrained by the effects of radiation to healthy tissue. With regard to patient exposure, the radiation protection framework of justification, optimization, and limitation is a direct part of the prescription process of radiation therapy. Staff and public exposures are typically far below occupational maximum permissible exposures. However, a number of other issues arise in radiation therapy that fall into the category of radiation protection...
February 2015: Health Physics
Douglas A Rahn, Gwe-Ya Kim, Arno J Mundt, Todd Pawlicki
PURPOSE: To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation. METHODS AND MATERIALS: On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment)...
December 1, 2014: International Journal of Radiation Oncology, Biology, Physics
Jung-In Kim, So-Yeon Park, Hak Jae Kim, Jin Ho Kim, Sung-Joon Ye, Jong Min Park
BACKGROUND: To investigate the sensitivity of various gamma criteria used in the gamma-index method for patient-specific volumetric modulated arc therapy (VMAT) quality assurance (QA) for stereotactic body radiation therapy (SBRT) using a flattening filter free (FFF) photon beam. METHODS: Three types of intentional misalignments were introduced to original high-definition multi-leaf collimator (HD-MLC) plans. The first type, referred to Class Out, involved the opening of each bank of leaves...
2014: Radiation Oncology
Janaki Krishnamoorthy, Adela Salame-Alfie, John O'Connell
From 2001 through 2009, the New York State Department of Health (NYSDOH) has documented 244 reports of radiation therapy events, of which 228 have resulted from the delivery of radiation beam therapy using linear accelerators (LINACs). Historically, radiation therapy events involving LINACs have not been uniformly reported across the country because LINACs are regulated by state radiation control programs, and reporting requirements vary among states. The Nuclear Regulatory Commission's Nuclear Material Events Database (NMED) only tracks events involving radioactive materials (RAM)...
May 2014: Health Physics
Camille E Noel, Veerarajesh Gutti, Walter Bosch, Sasa Mutic, Eric Ford, Stephanie Terezakis, Lakshmi Santanam
PURPOSE: To quantify the potential impact of the Integrating the Healthcare Enterprise-Radiation Oncology Quality Assurance with Plan Veto (QAPV) on patient safety of external beam radiation therapy (RT) operations. METHODS AND MATERIALS: An institutional database of events (errors and near-misses) was used to evaluate the ability of QAPV to prevent clinically observed events. We analyzed reported events that were related to Digital Imaging and Communications in Medicine RT plan parameter inconsistencies between the intended treatment (on the treatment planning system) and the delivered treatment (on the treatment machine)...
April 1, 2014: International Journal of Radiation Oncology, Biology, Physics
Stefania Clemente, Costanza Chiumento, Alba Fiorentino, Vittorio Simeon, Mariella Cozzolino, Caterina Oliviero, Giorgia Califano, Rocchina Caivano, Vincenzo Fusco
PURPOSE: To evaluate the usefulness of a six-degrees-of freedom (6D) correction using ExacTrac robotics system in patients with head-and-neck (HN) cancer receiving radiation therapy. METHODS: Local setup accuracy was analyzed for 12 patients undergoing intensity-modulated radiation therapy (IMRT). Patient position was imaged daily upon two different protocols, cone-beam computed tomography (CBCT), and ExacTrac (ET) images correction. Setup data from either approach were compared in terms of both residual errors after correction and punctual displacement of selected regions of interest (Mandible, C2, and C6 vertebral bodies)...
November 2013: Medical Physics
Sean L Berry, Cynthia Polvorosa, Simon Cheng, Israel Deutsch, K S Clifford Chao, Cheng-Shie Wuu
PURPOSE: To prospectively evaluate a 2-dimensional transit dosimetry algorithm's performance on a patient population and to analyze the issues that would arise in a widespread clinical adoption of transit electronic portal imaging device (EPID) dosimetry. METHODS AND MATERIALS: Eleven patients were enrolled on the protocol; 9 completed and were analyzed. Pretreatment intensity modulated radiation therapy (IMRT) patient-specific quality assurance was performed using a stringent local 3%, 3-mm γ criterion to verify that the planned fluence had been appropriately transferred to and delivered by the linear accelerator...
January 1, 2014: International Journal of Radiation Oncology, Biology, Physics
Cem Altunbas, Brian Kavanagh, Wayne Dzingle, Kelly Stuhr, Laurie Gaspar, Moyed Miften
Early experience with stereotactic body radiation therapy (SBRT) of centrally located lung tumors indicated increased rate of high-grade toxicity in the lungs. These clinical results were based on treatment plans that were computed using pencil beam-like algorithms and without tissue inhomogeneity corrections. In this study, we evaluated the dosimetric errors in plans with and without inhomogeneity corrections and with planning target volumes (PTVs) that were within the zone of the proximal bronchial tree (BT)...
2013: Medical Dosimetry: Official Journal of the American Association of Medical Dosimetrists
Bo Liu, Justus Adamson, Anna Rodrigues, Fugen Zhou, Fang-fang Yin, Qiuwen Wu
Volumetric modulated arc therapy (VMAT) is a relatively new treatment modality for dynamic photon radiation therapy. Pre-treatment quality assurance (QA) is necessary and many efforts have been made to apply electronic portal imaging device (EPID)-based IMRT QA methods to VMAT. It is important to verify the gantry rotation speed during delivery as this is a new variable that is also modulated in VMAT. In this paper, we present a new technique to perform VMAT QA using an EPID. The method utilizes EPID cine mode and was tested on Varian TrueBeam in research mode...
October 7, 2013: Physics in Medicine and Biology
James M Lamb, Nzhde Agazaryan, Daniel A Low
PURPOSE: To determine whether kilovoltage x-ray projection radiation therapy setup images could be used to perform patient identification and detect gross errors in patient setup using a computer algorithm. METHODS AND MATERIALS: Three patient cohorts treated using a commercially available image guided radiation therapy (IGRT) system that uses 2-dimensional to 3-dimensional (2D-3D) image registration were retrospectively analyzed: a group of 100 cranial radiation therapy patients, a group of 100 prostate cancer patients, and a group of 83 patients treated for spinal lesions...
October 1, 2013: International Journal of Radiation Oncology, Biology, Physics
R Mazeron, N Aguini, É Deutsch
Five radiotherapy accidents, from which two serial, occurred in France from 2003 to 2007, led the authorities to establish a roadmap for securing radiotherapy. By analogy with industrial processes, a technical decision form the French Nuclear Safety Authority in 2008 requires radiotherapy professionals to conduct analyzes of risks to patients. The process of risk analysis had been tested in three pilot centers, before the occurrence of accidents, with the creation of cells feedback. The regulation now requires all radiotherapy services to have similar structures to collect precursor events, incidents and accidents, to perform analyzes following rigorous methods and to initiate corrective actions...
July 2013: Cancer Radiothérapie: Journal de la Société Française de Radiothérapie Oncologique
Prajnan Das, Jennifer Johnson, Sandra E Hayden, Beverly A Riley, Scott Harrelson, Michael Gillin, Geoffrey Ibbott, Thomas A Buchholz
PURPOSE: The goals of this study were to determine the rate of radiation therapy patient events at a large academic institution and to evaluate temporal trends in this rate using statistical process control tools. METHODS: An incident reporting system was used to prospectively collect information on radiation therapy patient events and near misses or good catches, using paper-based reports through December 2010 and an online electronic reporting system from January 2011 onward...
June 2013: Journal of the American College of Radiology: JACR
John A Kalapurakal, Aleksandar Zafirovski, Jeffery Smith, Paul Fisher, Vythialingam Sathiaseelan, Cynthia Barnard, Alfred W Rademaker, Nick Rave, Bharat B Mittal
PURPOSE: This report describes the value of a voluntary error reporting system and the impact of a series of quality assurance (QA) measures including checklists and timeouts on reported error rates in patients receiving radiation therapy. METHODS AND MATERIALS: A voluntary error reporting system was instituted with the goal of recording errors, analyzing their clinical impact, and guiding the implementation of targeted QA measures. In response to errors committed in relation to treatment of the wrong patient, wrong treatment site, and wrong dose, a novel initiative involving the use of checklists and timeouts for all staff was implemented...
June 1, 2013: International Journal of Radiation Oncology, Biology, Physics
(no author information available yet)
Surgical errors recorded between 2002 and 2008 in a US medical liability insurance database have been analysed. Twenty-five wrong-patient procedures were recorded, resulting in 5 serious adverse events: three unnecessary prostatectomies were performed after prostate biopsy samples were mislabelled; vitrectomy was performed on the wrong patient in an ophthalmology department after confusion between two patients with identical names; and a child scheduled for adenoidectomy received a tympanic drain. There were also 107 wrong-site procedures, with one death resulting from implantation of a pleural drain on the wrong side...
January 2013: Prescrire International
Albin Fredriksson
PURPOSE: To characterize a class of optimization formulations used to handle systematic and random errors in radiation therapy, and to study the differences between the methods within this class. METHODS: The class of robust methods that can be formulated as minimax stochastic programs is studied. This class generalizes many previously used methods, ranging between optimization of the expected and the worst case objective value. The robust methods are used to plan intensity-modulated proton therapy (IMPT) treatments for a case subject to systematic setup and range errors, random setup errors with and without uncertain probability distribution, and combinations thereof...
August 2012: Medical Physics
Neil D'Souza, Lori Holden, Sheila Robson, Kathy Mah, Lisa Di Prospero, C Shun Wong, Edward Chow, Jacqueline Spayne
PURPOSE: To examine whether treatment workload and complexity associated with palliative radiation therapy contribute to medical errors. METHODS AND MATERIALS: In the setting of a large academic health sciences center, patient scheduling and record and verification systems were used to identify patients starting radiation therapy. All records of radiation treatment courses delivered during a 3-month period were retrieved and divided into radical and palliative intent...
September 1, 2012: International Journal of Radiation Oncology, Biology, Physics
Hiroko Yamaguchi, Mitsuhiro Matsumoto, Seiichi Ohta, Takahiko Ueda, Yasuhiro Tsutsui
INTRODUCTION: We verified the setup error (SE) in two persons' radiation therapist's team, which consist of staff and new face. We performed the significance test for SE by the staff group and the new face group. METHODS: One group consists of four staff therapists with at least 5 to 30 years of experience. The other group consists of new face radiation therapists that have 1 to 1.5 years of experience. Analyzed were 53 patients diagnosed with pelvic cancer (seven patients who underwent 3 dimensional conformal radiation therapy (3DCRT) and 46 patients who underwent intensity modulated radiation therapy (IMRT)...
2012: Nihon Hoshasen Gijutsu Gakkai Zasshi
Eric C Ford, Stephanie Terezakis, Annette Souranis, Kendra Harris, Hiram Gay, Sasa Mutic
PURPOSE: To quantify the error-detection effectiveness of commonly used quality control (QC) measures. METHODS: We analyzed incidents from 2007-2010 logged into a voluntary in-house, electronic incident learning systems at 2 academic radiation oncology clinics. None of the incidents resulted in patient harm. Each incident was graded for potential severity using the French Nuclear Safety Authority scoring scale; high potential severity incidents (score >3) were considered, along with a subset of 30 randomly chosen low severity incidents...
November 1, 2012: International Journal of Radiation Oncology, Biology, Physics
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