Prog Med Phys.  2014 Dec;25(4):298-303. 10.14316/pmp.2014.25.4.298.

Radiotherapy Incidents Analysis Based on ROSIS: Tendency and Frequency

• Koo J
• Yoon M
• Chung WK
• Kim DW

• KMID: 2315770
• DOI: http://doi.org/10.14316/pmp.2014.25.4.298

Abstract

In this study, we examine the trends and types of incidents frequently occur during radiation therapy by using the data from the radiation oncology safety information system (ROSIS), according to discovery method explores the development direction of future research accident cause factor control method. This study was carried out analysis of incident data in ROSIS nearly 1163 cases in last 11 years from 2003 to 2013. We categorized into treatment methods, found the time, discoverer of occupations and finding ways to analyze the data. Then, we calculate the percentage and the classification for each item. About 1163 cases of incident cases including the near miss cases, external radiation therapy, brachytherapy and other were 97%, 2% and 1%. In the case was improperly planned dose delivery was 44% (497 cases) which 429 cases (86%) was found before 3 fractions and 13 cases were found after 11 fractions. The investigation was found to be distributed in various a found times. Approximately 42% of found time was during treatment and 29% of patients were found the problem during inspection chart. Occupation to discover the most radiation accidents was the radiation therapist (53%) who works in treatment room. Among 1163 incidence cases, 24% cases were found the accident before the treatment, therefore most of accident were found after of during the treatment (70%, 813 cases). This trend is acquired through ROSIS analysis, is expected to be not significantly different in the case of Korea, so it is necessary more diverse and systematic research for the prevention and early detection by using the ROSIS data.

Keyword

Radiation treatment safety; ROSIS; Quality assurance; Radiotherapy Incidents; Near-Miss

MeSH Terms

Brachytherapy
Classification
Humans
Incidence
Information Systems
Korea
Occupations
Radiation Oncology
Radioactive Hazard Release
Radiotherapy*

Figure

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  Fig. 1. Technique used at the time of radiation incidents or near-misses.

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  Fig. 2. Number of incident types in each treatment process (external beam therapy) based on ROSIS data.

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  Fig. 3. Percentage of incidents which was caused by human factor.

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  Fig. 4. Step of process that incidents or near-misses were detected.

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  Fig. 5. Occupation of detected person. (a) therapist; (b) unknown; (c) physicist; (d) oncologist; (e) therapist (Sim/CT); (f) dosimetrist; (g) other.

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  Fig. 6. QA method which was used to detect incidents or near-misses. (a) found at time of patient treatment; (b) chart check; (c) other; (d) portal imaging; (e) clinical review of patient; (f) quality control equipment; (g) in-vivo dosimetry; (h) external audit.

Reference

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