Radiotherapy Incidents Analysis Based on ROSIS: Tendency and Frequency

Jihye Koo; MyongGeun Yoon; Won Kuu Chung; Dong Wook Kim

doi:10.14316/pmp.2014.25.4.298

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Koo, Yoon, Chung, and Kim: Radiotherapy Incidents Analysis Based on ROSIS: Tendency and Frequency

Technical Report

Progress in Medical Physics 2014;25(4):298-303.

Published online: 20 January 2014

DOI: https://doi.org/10.14316/pmp.2014.25.4.298

Radiotherapy Incidents Analysis Based on ROSIS: Tendency and Frequency

Jihye Koo^∗, MyongGeun Yoon^†, Won Kuu Chung^‡, Dong Wook Kim^‡

^∗Department of Radiologic Science, Seoul, Korea

^†Department of Bio-Convergence Engineering, Korea University, College of Health Science, Korea University, College of Health Science, Seoul, Korea

^‡Department of Radiation Oncology, Kyung Hee University Hospital at Gangdong, Seoul, Korea

Correspondence: Dong Wook Kim (joocheck@gmail.com) Tel:82-2-440-7390, Fax:82-2-440-7393

Received 6 November 2014 Revised 17 November 2014 Accepted 24 November 2014

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Radiation treatment safety, ROSIS, Quality assurance, Radiotherapy Incidents, Near-Miss

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Fig. 1.

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

Fig. 2.

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

Fig. 3.

Percentage of incidents which was caused by human factor.

Fig. 4.

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

Fig. 5.

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

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.

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