Brachytherapy patient safety events in an academic radiation medicine program

Felder, Shira; Morley, Lyndon; Ng, Elizabeth; Chan, KH; Ballantyne, Heather; Tomasso, Anne Di; Borg, Jette; Bissonnette, Jean‐Pierre; Breen, Stephen; Waldron, John; Rink, Alexandra; Milosevic, Michael

doi:10.1016/j.brachy.2017.06.010

Cited by 13 publications

(5 citation statements)

References 29 publications

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“…Most causes of these events were human errors that were related to treatment planning or commissioning [1,5,10]. Few reports Reports also revealed the incidence of all brachytherapy events to be 0.02-1.6% [6,8,9]. Accordingly, it is assumed that the incidence rate of malfunctioning events is low.…”

Section: Discussionmentioning

confidence: 99%

“…Another single-institution survey revealed that the incidence of HDR brachytherapy events occurring between 2010 and 2013 was 0.27%, of which 0.15% affected patient safety [8]. Furthermore, according to reports using the recent incident reporting system, the incident rate, including that of incidents, near misses, and programmatic hazards, for 10 years was 1.6% [9].…”

Section: Purposementioning

confidence: 99%

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First experience of 192Ir source stuck event during high-dose-rate brachytherapy in Japan

Kumagai¹,

Arai²,

Takata³

et al. 2020

jcb

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Purpose: To share the experience of an iridium-192 (192 Ir) source stuck event during high-dose-rate (HDR) brachytherapy for cervical cancer. Material and methods: In 2014, we experienced the first source stuck event in Japan when treating cervical cancer with HDR brachytherapy. The cause of the event was a loose screw in the treatment device that interfered with the gear reeling the source. This event had minimal clinical effects on the patient and staff; however, after the event, we created a normal treatment process and an emergency process. In the emergency processes, each staff member is given an appropriate role. The dose rate distribution calculated by the new Monte Carlo simulation system was used as a reference to create the process. Results: According to the calculated dose rate distribution, the dose rates inside the maze, near the treatment room door, and near the console room were ≅ 10-2 [cGy · h-1 ], 10-3 [cGy · h-1 ], and << 10-3 [cGy · h-1 ], respectively. Based on these findings, in the emergency process, the recorder was evacuated to the console room, and the rescuer waited inside the maze until the radiation source was recovered. This emergency response manual is currently a critical workflow once a year with vendors. Conclusions: We reported our experience of the source stuck event. Details of the event and proposed emergency process will be helpful in managing a patient safety program for other HDR brachytherapy users.

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Section: Discussionmentioning

confidence: 99%

Section: Purposementioning

confidence: 99%

First experience of 192Ir source stuck event during high-dose-rate brachytherapy in Japan

Kumagai¹,

Arai²,

Takata³

et al. 2020

jcb

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“…Felder et al . reported a safety-related event rate of 2.8% for BT patients and 1.7% for BT fractions [ 35 ]. Adverse events associated with afterloading HDR-BT reported to the United States Food and Drug Administration were also described by Provenzano et al .…”

Section: Discussionmentioning

confidence: 99%

Patient safety program and incident review of high-dose-rate brachytherapy at an academic center in Thailand

Tuntipumiamorn¹,

Kamplong²,

Pengchantr³

et al. 2022

jcb

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Purpose: An incident review of errors related to using high-dose-rate brachytherapy (HDR-BT) and associated patient safety program were presented. This study was based on 9 years' experience using VariSource afterloader system.Material and methods: Analysis was made on radiotherapy (RT) incidents (including near-misses) that were routinely recorded using manual and electronic incident reporting systems between July 2012 and December 2021. Each incident's origin was categorized as 'apparatus', 'system functionality', 'treatment procedure', and 'other causes'.Results: From 8,100 fractions and 2,216 patients, there were 164 RT incidents. The most frequent cases included non-dosimetric errors arising from system malfunction (49/151), difficulties caused by insufficient instruments (47/151), problems with treatment delivery (55/151), and planning procedure errors (13/142). Eleven incidents were near-misses, another 11 were not harmful, and zero were harmful. The frequency rate of dosimetric errors was 0.14 per 100 BT insertions, and 0.5 per 100 patients. The review also discovered 45 of the 164 incidents related to tube sensor failures and source blockages. These delivery errors were associated with 0.56 incidents per 100 insertions and 2.03 incidents per 100 patients, inconveniencing patients in treatment delays.Conclusions: The effectiveness of our HDR-BT safety program was evidenced by low-rate of dosimetric errors. Based on the analysis of 9 years of incidents, the error sources included uncommon or complex procedures, human factors, and work environment (equipment availability and maintenance).

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“…Retrospectively reviewing brachytherapy safety events, in particular, in another study [30], the records from an incident reporting system were retrieved. The study period was approximately 9.5 years, when 3095 patients received 4967 brachytherapy fractions.…”

Section: Medical Therapeutic Uses Of Radiationmentioning

confidence: 99%

How often does it happen? A review of unintended, unnecessary and unavoidable high-dose radiation exposures

Holmberg¹,

Pinák²

2021

J. Radiol. Prot.

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High-dose radiation exposures of humans occur every year around the world, and may lead to harmful tissue reactions. This review aims to look at the available information sources that can help answering the question of how often these events occur yearly on a global scale. In the absence of comprehensive databases of global occurrence, publications on radiation accidents in all uses of radiation and on rates of high-dose events in different medical uses of radiation have been reviewed. Most high-dose radiation exposures seem to occur in the medical uses of radiation, reflecting the high number of medical exposures performed. In therapeutic medical uses, radiation doses are purposely often given at levels known to cause deterministic effects, and there is a very narrow range in which the medical practitioner can operate without causing severe unacceptable outcomes. In interventional medical uses, there are scenarios in which the radiation dose given to a patient may reach or exceed a threshold for skin effects, where this radiation dose may be unavoidable, considering all benefits and risks as well as benefits and risks of any alternative procedures. Regardless of if the delivered dose is unintended, unnecessary or unavoidable, there are estimates published of the rates of high-dose events and of radiation-induced tissue injuries occurring in medical uses. If this information is extrapolated to a global scenario, noting the inherent limitations in doing so, it does not seem unreasonable to expect that the global number of radiation-induced injuries every year may be in the order of hundreds, likely mainly arising from medical uses of radiation, and in particular from interventional fluoroscopy procedures and external beam radiotherapy procedures. These procedures are so frequently employed throughout the world that even a very small rate of radiation-induced injuries becomes a substantial number when scaled up to a global level.

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Brachytherapy patient safety events in an academic radiation medicine program

Cited by 13 publications

References 29 publications

First experience of 192Ir source stuck event during high-dose-rate brachytherapy in Japan

First experience of 192Ir source stuck event during high-dose-rate brachytherapy in Japan

Patient safety program and incident review of high-dose-rate brachytherapy at an academic center in Thailand

How often does it happen? A review of unintended, unnecessary and unavoidable high-dose radiation exposures

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