Prevention of Accidental Exposure in Radiotherapy

Abstract

Knowledge and lessons from past accidental exposures in radiotherapy are very helpful in finding safety provisions to prevent recurrence. Disseminating lessons is necessary but not sufficient. There may be additional latent risks for other accidental exposures, which have not been reported or have not occurred, but are possible and may occur in the future if not identified, analyzed, and prevented by safety provisions. Proactive methods are available for anticipating and quantifying risk from potential event sequences. In this work, proactive methods, successfully used in industry, have been adapted and used in radiotherapy. Risk matrix is a tool that can be used in individual hospitals to classify event sequences in levels of risk. As with any anticipative method, the risk matrix involves a systematic search for potential risks; that is, any situation that can cause an accidental exposure. The method contributes new insights: The application of the risk matrix approach has identified that another group of less catastrophic but still severe single-patient events may have a higher probability, resulting in higher risk. The use of the risk matrix approach for safety assessment in individual hospitals would provide an opportunity for self-evaluation and managing the safety measures that are most suitable to the hospital's own conditions.

Improving safety in radiotherapy: The implementation of the Global Risk Analysis method

“…The FORO (Foro Iberoamericano de Organismos Reguladores Radiológicos y Nucleares) also developed a dedicated tool, promoted in Spain. The originality of this method is to focus on the ''barriers'', which are the measures that can limit the probability of occurrence of an event or its severity [23]. It can be applied in addition to other methods like the GRA or FMEA focusing on the identification and prevention of risks.…”

"Improving Radiation Oncology Safety in Spain with Risk Matrices: a Review: The MARR Project"

“…The results of the application of this matrix in different facilities were presented as communications at several Ibero-American conferences [4,5] and led to national and international publications [6,7]. We also developed a computer application known as SEVRRA [8][9][10] to facilitate the analysis of these services.…”

Risk management in radiation therapy with SEVRRA

“…The Ibero-American Forum of Radiological and Nuclear Regulatory Agencies (FORO) [14] [1,[15][16][17][18]. SEVRRA is an online tool that implements the risk matrix method applied to radiotherapy [2,17,19] also developed under the FORO, dealing semi-quantitatively with both retrospective and prospective risk analysis approaches. It is ready to perform a prescriptive risk assessment for the modalities of 3D conformational radiation teletherapy with linear accelerator and Cobalt 60 unit, High Dose [7] and Low Dose Rate Brachytherapy [2,17,19,20].…”