SU‐E‐T‐257: Examination of Medical Events on High‐Dose‐Rate Brachytherapy Repored to the NRC

C. Saw, J. Juliano, Henry Wagner Jr.

Research output: Contribution to journalArticle

Abstract

Purpose: A series of reports on medical errors recently published in New York Times highlights the need to be aware of patient safety in radiation medicine. Various groups are using the risk assessment technique to reduce medical errors. This work examined medical events associated with high‐dose‐rate (HDR) brachytherapy as reported and posted on the NRC website to understand the causes of these medical events. Methods: A task was undertaken to systematically assess the notification of events as reported to the NRC from January 2010 to March 2011. These notifications include all events under the jurisdiction of the NRC from nuclear power to the medical use of byproduct materials. Eleven notification events associated with HDR brachytherapy were identified for this time period. These notifications were read and discussed to identify the possible causes of these medical events. Results: Among these medical events, two were related to equipment failure: the failure to withdraw source and the punching through a catheter by the source. One of the event was due to a software bug. The rest of the events were associated with human errors. The first event was associated with inadvertent pressing of the auto‐radiography button instead of the treatment button. The rest of the events were due to incorrect determination of the length of the catheter, the dwell spacing, or the data entry in the treatment planning system. These occurrences point directly at the need for a checklist to remind the medical physicist to review these parameters prior to dose delivery. Conclusions: A systematic checklist that incorporates the reevaluation of the (a) length of catheter, (b) dwell spacing, and (c) data entered into the treatment planning system would eliminate over 60% of the error seen last year and early part of this year.

Original languageEnglish (US)
Number of pages1
JournalMedical Physics
Volume38
Issue number6
DOIs
StatePublished - Jan 1 2011

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Brachytherapy
Medical Errors
Catheters
Checklist
Equipment Failure
Patient Safety
Autoradiography
Therapeutics
Software
Medicine
Radiation

All Science Journal Classification (ASJC) codes

  • Biophysics
  • Radiology Nuclear Medicine and imaging

Cite this

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title = "SU‐E‐T‐257: Examination of Medical Events on High‐Dose‐Rate Brachytherapy Repored to the NRC",
abstract = "Purpose: A series of reports on medical errors recently published in New York Times highlights the need to be aware of patient safety in radiation medicine. Various groups are using the risk assessment technique to reduce medical errors. This work examined medical events associated with high‐dose‐rate (HDR) brachytherapy as reported and posted on the NRC website to understand the causes of these medical events. Methods: A task was undertaken to systematically assess the notification of events as reported to the NRC from January 2010 to March 2011. These notifications include all events under the jurisdiction of the NRC from nuclear power to the medical use of byproduct materials. Eleven notification events associated with HDR brachytherapy were identified for this time period. These notifications were read and discussed to identify the possible causes of these medical events. Results: Among these medical events, two were related to equipment failure: the failure to withdraw source and the punching through a catheter by the source. One of the event was due to a software bug. The rest of the events were associated with human errors. The first event was associated with inadvertent pressing of the auto‐radiography button instead of the treatment button. The rest of the events were due to incorrect determination of the length of the catheter, the dwell spacing, or the data entry in the treatment planning system. These occurrences point directly at the need for a checklist to remind the medical physicist to review these parameters prior to dose delivery. Conclusions: A systematic checklist that incorporates the reevaluation of the (a) length of catheter, (b) dwell spacing, and (c) data entered into the treatment planning system would eliminate over 60{\%} of the error seen last year and early part of this year.",
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SU‐E‐T‐257 : Examination of Medical Events on High‐Dose‐Rate Brachytherapy Repored to the NRC. / Saw, C.; Juliano, J.; Wagner Jr., Henry.

In: Medical Physics, Vol. 38, No. 6, 01.01.2011.

Research output: Contribution to journalArticle

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