A Quality Assurance Program For Personnel And Procedures In Radiosurgery: On Target For 2010?Keywords: Radiation Therapy, physics, error, Radiation Techniques, dose deliveryInteractive Manuscript
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What is the background behind your study?
While major efforts have been focused on quality assurance (QA) of stereotactic radiosurgery (SRS) equipment, human errors are the most common source of deviations/incidents during RT delivery.
What is the purpose of your study?
This report describes the frequency of RT deviations (RTD) and the guidelines/protocols that were implemented with emphasis on radiation oncology personnel and procedures.
Describe your patient group.
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Describe what you did.
The departmental QA committee has maintained a record of RTD voluntarily reported by our staff. These incidents were reviewed during monthly departmental and hospital-level meetings. A number of corrective measures and recommendations were made to reduce the frequency of such errors.
Describe your main findings.
Between 2001 and 2008, 121 RTD were recorded. During this period a total of 197,865 external radiation therapy (RT) treatments were delivered. The RTD were classified into four categories: Machine/accessory errors 6.6% (8/121), documentation errors 4.2% (5/121), treatment planning errors 21.5% (26/121) and patient set-up errors 72.7% (88/121). The most common patient set-up errors related to wrong isocenter (n=21), wrong blocks (n=16), bolus placement (n=12), wrong SAD/SSD (n=10) and patient data mismatch(n=10).
Describe the main limitation of this study.
This data was collected on an ongoing basis and was reviewed retrospectively.
Describe your main conclusion.
It is important to recognize that all members of the team including physicians are likely to commit errors. The measures adopted here have targeted all the main domains of activity in our department.
Describe the importance of your findings and how they can be used by others.
These and other measures are very important in implementing a comprehensive QA program geared towards meeting the future goals and complex challenges in our field.
While major efforts have been focused on quality assurance (QA) of stereotactic radiosurgery (SRS) equipment, human errors are the most common source of deviations/incidents during RT delivery.
This report describes the frequency of RT deviations (RTD) and the guidelines/protocols that were implemented with emphasis on radiation oncology personnel and procedures.
The departmental QA committee has maintained a record of RTD voluntarily reported by our staff. These incidents were reviewed during monthly departmental and hospital-level meetings. A number of corrective measures and recommendations were made to reduce the frequency of such errors.
Between 2001 and 2008, 121 RTD were recorded. During this period a total of 197,865 external radiation therapy (RT) treatments were delivered. The RTD were classified into four categories: Machine/accessory errors 6.6% (8/121), documentation errors 4.2% (5/121), treatment planning errors 21.5% (26/121) and patient set-up errors 72.7% (88/121). The most common patient set-up errors related to wrong isocenter (n=21), wrong blocks (n=16), bolus placement (n=12), wrong SAD/SSD (n=10) and patient data mismatch(n=10).
This data was collected on an ongoing basis and was reviewed retrospectively.
It is important to recognize that all members of the team including physicians are likely to commit errors. The measures adopted here have targeted all the main domains of activity in our department.
These and other measures are very important in implementing a comprehensive QA program geared towards meeting the future goals and complex challenges in our field.
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