Research Article | Open Access | 10.31586/Radiology.0403.01
A Tool for Reporting and Evaluation of Incidents in External Beam Radiation Therapy
Received January 22, 2019
Revised February 23, 2019
Accepted February 27, 2019
Published March 1, 2019
AbstractThe number of cases of cancer has significantly increased in the world and the use of ionizing radiation produced by large clinical linear accelerators plays an important role in the treatment of tumors. Although radiotherapy is considered a safe medical practice, it may bring some risks for the patient and in some extreme cases even her/his death. Over the last decades, the learning with incidents there has been a powerful way to prevent them to turn to happen. In this work a digital tool was developed for recording and evaluation of incidents in external beam radiation therapy. The tool was designed to function in an intranet environment, but it can also be used in the offline mode and is based on a set of sequential forms filled by the user (e.g. medical physicists, medical dosimetrists, radiation oncologists, radiotherapy technicians). The software was firstly applied in a radiation oncology department of a public Institution in Rio de Janeiro, Brazil. The software has proved to be an important and promising tool to improve the healthcare quality of patients undergoing radiation therapy.
World Health Organization. Available from http://gco.iarc.fr/tomorrow/home.
Begg AC, Stewart FA, Vens C. Strategies to improve radiotherapy with targeted drugs. Nat Rev Cancer 2011; 11: 239-253.
Bogdanich W. Radiation offers new cures, and ways to do harm. New York, NY: New York Times 2010: 1.
Hendee WR, Herman MG. Improving patient safety in radiation oncology. Med Phys 2011; 38: 78-82.
Ford EC, Los Santos LF, Pawlicki T, et al. Consensus recommendations for incident learning database structures in radiation oncology. Med Phys 2012; 39: 7272-7290.
Macklis RM, Meier T, Weinhous MS. Error rates in clinical radiotherapy. J Clin Oncol 1998; 16: 551-556.
Holmberg O, McClean B. Preventing treatment errors in radiotherapy by identifying and evaluating near misses and actual incidents. J Radiother Prac 2002; 3: 13-25.
Donaldson L. Towards Safer Radiotherapy. British Institute of Radiology, Institute of Physics and Engineering in Medicine, National Patient Safety Agency, Society and College of Radiographers, The Royal College of Radiologists, London, 2007.
Pawlicki T, Mundt AJ. Quality in radiation oncology. Med Phys 2007; 34: 1529-1534.
Boadu M, Rehani MM. Unintended exposure in radiotherapy: identification of prominent causes. Radiother Oncol 2009; 93: 609-617.
Ford EC, Terezakis S. How safe is safe? Risk in radiotherapy. Int J Radiat Oncol Biol Phys 2010; 78: 321-322.
Mutic S, Brame RS, Oddiraju S, et al. Event (error and near-miss) reporting and learning system for process improvement in radiation oncology. Med Phys 2010; 37: 5027-5036.
Ford EC, Terezakis S, Souranis A, et al. Quality control quantification (QCQ): a tool to measure the value of quality control checks in radiation oncology. Int J Radiat Oncol Biol Phys 2012; 84: e263-e269.
Clark BG, Brown RJ, Ploquin J, Dunscombe P. Patient safety improvements in radiation treatment through 5 years of incident learning. Pract Radiat Oncol 2013; 3: 157-163.
Nyflot MJ, Zeng J, Kusano AS, et al. Metrics of success: measuring impact of a departmental near-miss incident learning system. Pract Radiat Oncol 2015; 5: e409-e416.
Novak A, Nyflot MJ, Ermoian RP, et al. Targeting safety improvements through identification of incident origination and detection in a near miss incident learning system. Med Phys 2016; 43: 2053-2062.
Ford EC, Evans SB. Incident learning in radiation oncology: a review. Med Phys 2018; 45: e100-e119.
Donaldson L. Radiotherapy Risk Profile: Technical Manual. Geneva, Switzerland: World Health Organization; 2008.
Ortiz LP, Cossett JM, Dunscombe P, et al. ICRP Report No. 112. Preventing accidental exposures from new external beam radiation therapy technologies. ICRP; 2009. 112.
American Society for Radiation Oncology. Safety is No Accident, 2012. Available from: https://www.astro.org/Clinical-Practice/Patient-Safety-Book/Safety-Is-No-Accident.aspx
ASTRO. Accreditation Program for Excellence (APEx). 2017. Available from: https://www.astro.org/apex/.
Hoopes DJ, Dicker AP, Eads NL, et al. RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience. Pract Radiat Oncol 2015; 5: 312-318.
IAEA. Safety Reporting and Learning System for Radiotherapy (SAFRON). 2017. Available from: https://rpop.iaea.org/RPOP/RPoP/Modules/login/safron-register.htm.