"Medical error" "radiation therapy"

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...

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...

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)...

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...

PURPOSE: To identify deficiencies with simulation and treatment planning orders and to develop corrective measures to improve safety and quality. METHODS AND MATERIALS: At Washington University, the DMAIIC formalism is used for process management, whereby the process is understood as comprising Define, Measure, Analyze, Improve, Implement, and Control activities. Two complementary tools were used to provide quantitative assessments: failure modes and effects analysis and reported event data...

PURPOSE: To determine whether the use of routine image guided radiation therapy (IGRT) using pretreatment on-board imaging (OBI) with orthogonal kilovoltage X-rays reduces treatment delivery errors. METHODS AND MATERIALS: A retrospective review of documented treatment delivery errors from 2003 to 2009 was performed. Following implementation of IGRT in 2007, patients received daily OBI with orthogonal kV X-rays prior to treatment. The frequency of errors in the pre- and post-IGRT time frames was compared...

Delivering radiation therapy in an oncology setting is a high-risk process where system failures are more likely to occur because of increasing utilization, complexity, and sophistication of the equipment and related processes. Healthcare failure mode and effect analysis (FMEA) is a method used to proactively detect risks to the patient in a particular healthcare process and correct potential errors before adverse events occur. FMEA is a systematic, multidisciplinary team-based approach to error prevention and enhancing patient safety...

No abstract text is available yet for this article.

PURPOSE: The authors hereby notify the Radiation Oncology community of a potentially lethal error due to improper implementation of linear units of measure in a treatment planning system. The authors report an incident in which a patient was nearly mistreated during a stereotactic radiotherapy procedure due to inappropriate reporting of stereotactic coordinates by the radiation therapy treatment planning system in units of centimeter rather than in millimeter. The authors suggest a method to detect such errors during treatment planning so they are caught and corrected prior to the patient positioning for treatment on the treatment machine...

BACKGROUND: Safety initiatives in the United States continue to work on providing guidance as to how the average practitioner might make patients safer in the face of the complex process by which radiation therapy (RT), an essential treatment used in the management of many patients with cancer, is prepared and delivered. Quality control measures can uncover certain specific errors such as machine dose miscalibration or misalignments of the patient in the radiation treatment beam. However, they are less effective at uncovering less common errors that can occur anywhere along the treatment planning and delivery process, and even when the process is functioning as intended, errors still occur...

PURPOSE: Technological advances in radiation therapy (RT) delivery have the potential to reduce errors via increased automation and built-in quality assurance (QA) safeguards, yet may also introduce new types of errors. Intensity-modulated RT (IMRT) is an increasingly used technology that is more technically complex than three-dimensional (3D)-conformal RT and conventional RT. We determined the rate of reported errors in RT delivery among IMRT and 3D/conventional RT treatments and characterized the errors associated with the respective techniques to improve existing QA processes...

PURPOSE: To compare the effect of respiration-induced motion on delivered dose (the interplay effect) for different treatment techniques under realistic clinical conditions. METHODS: A flexible resin tumor model was created using rapid prototyping techniques based on a computed tomography (CT) image of an actual tumor. Twenty micro-MOSFETs were inserted into the tumor model and the tumor model was inserted into an anthropomorphic breathing phantom. Phantom motion was programed using the motion trajectory of an actual patient...

BACKGROUND AND PURPOSE: The Radiation Oncology Safety Information System (ROSIS) was established in 2001. The aim of ROSIS is to collate and share information on incidents and near-incidents in radiotherapy, and to learn from these incidents in the context of departmental infrastructure and procedures. MATERIALS AND METHODS: A voluntary web-based cross-organisational and international reporting and learning system was developed (cf. the www.rosis.info website). Data is collected via online Department Description and Incident Report Forms...

BACKGROUND AND PURPOSE: New radiation therapy technologies can enhance the quality of treatment and reduce error. However, the treatment process has become more complex, and radiation dose is not always delivered as intended. Using human factors methods, a radiotherapy treatment delivery process was evaluated, and a redesign was undertaken to determine the effect on system safety. MATERIAL AND METHODS: An ethnographic field study and workflow analysis was conducted to identify human factors issues of the treatment delivery process...

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)...

PURPOSE: To assess efficacy of an incident learning system in the management of error in radiation treatment. MATERIALS AND METHODS: We report an incident learning system implementation customized for radiation therapy where any "unwanted or unexpected change from normal system behaviour that causes or has the potential to cause an adverse effect to persons or equipment" is reported, investigated and learned from. This system thus captures near-miss (potential) and actual events...

No abstract text is available yet for this article.

AIMS AND BACKGROUND: With the introduction of more complex three-dimensional conformal radiotherapy and intensity-modulated radiotherapy techniques in clinical practice, the use of record-and-verify systems is recommended to improve the accuracy of radiotherapy treatments. The aim of the present study was to evaluate, for a commercial record-and-verify system, the efficiency, integration with the treatment planning system, and impact of manual checking of data. The most frequent errors or misses were also evaluated...

BACKGROUND AND PURPOSE: The Tomotherapy Hi-Art II system allows acquisition of pre-treatment MVCT images to correct patient position. This work evaluates the dosimetric impact of uncorrected setup errors in breast-cancer radiation therapy. MATERIALS AND METHODS: Breast-cancer patient-positioning errors were simulated by shifting the patient computed-tomography (CT) dataset relative to the planned photon fluence and re-computing the dose distributions. To properly evaluate the superficial region, film measurements were compared against the Tomotherapy treatment planning system (TPS) calculations...

PURPOSE: To study the impact of setup errors on the dose to the target volume and critical structures in the treatment of cancer of nasopharynx with intensity modulated radiation therapy (IMRT). METHODS AND MATERIALS: Twelve patients of carcinoma of nasopharynx treated by IMRT with simultaneous integrated boost technique were enrolled. The gross tumor volume, clinical target volume and low-risk nodal region were planned for 70, 59.4 and 54 Gy, respectively, in 33 fractions...