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Oh, Kim, Yea, Kang, Lee, and Lee: Basic Data Analysis of the Quality Control for Patient Safety in Department of Radiation Oncology at Yeungnam University Hospital
Original Article

Progress in Medical Physics 2015;26(2):112-117.

Published online: 20 June 2015

DOI: https://doi.org/10.14316/pmp.2015.26.2.112

Basic Data Analysis of the Quality Control for Patient Safety in Department of Radiation Oncology at Yeungnam University Hospital

Se An Oh∗, Sung Kyu Kim†, Ji Woon Yea†, Min Kyu Kang†, Joon Ha Lee‡, Rena Lee§

∗Department of Radiation Oncology, Yeungnam University Medical Center, Daegu, Korea

†Department of Radiation Oncology, Yeungnam University College of Medicine, Daegu, Korea

‡Department of Medical Biochemistry and Molecular Biology, Yeungnam University College of Medicine, Daegu, Korea

§Department of Radiation Oncology, School of Medicine, Ewha Womans University, Seoul, Korea

Correspondence: Sung Kyu Kim (skkim3@ynu.ac.kr) Tel:82-53-620-3373, Fax:82-53-624-3599

Received 16 May 2015       Revised 17 June 2015       Accepted 18 June 2015

Copyright © 2015 Korean Society of Medical Physics

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 order to establish the quality control on patient safety following the guideline presented by American Association of Physicists in Medicine (AAPM) TG-100 committee, we aim to analyze the modes based on errors occurred during treatment of patients at the radiation oncology department at Yeungnam University Hospital and establish a quality control guideline for patient safety when patient-centered radiation treatment is conducted. We aim to analyze the errors that can occur during radiation treatment at the radiation department, and assess the frequency of error, the severity of error affecting patients, and probability of proceeding without noticing error, with scores. The places where errors can take place were divided into CT simulation treatment room, treatment planning room, and treatment room for the analysis. In CT simulation treatment room, an error from using the immobilization device showed the highest Risk Priority Number (RPN) value of 60, and an error from simulation treatment information input showed the lowest of 6. In treatment planning room, an error from selecting the radiation dose calculation model showed the highest RPN value of 168, and an error of patient treatment start date showed the lowest of 36. In treatment room, a Table Bar error showed the highest RPN value of 252, a weight change error showed 190, and a Pillow error showed the lowest of 24.

Keywords: AAPM TG-100, Patient safety, Error analysis, Risk priority number

References

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Table 1.
Probability that a specific cause will result in a failure mode.1)
Qualitative review Ranking Frequency of occurrence
Failure is unlikely 1 1/10,000
  2 2/10,000
Relatively few failures 3 5/10,000
  4 1/1000
  5 <0.2%
Occasional failures 6 <0.5%
  7 <1.0%
Repeated failures 8 <2.0%
  9 <5.0%
Failures are common 10 >5.0%
Table 2.
Severity of the effects resulting from a specific failure mode.1)
Qualitative review Ranking
Not noticeable, no effect on the patient or 1
on the department  
Inconvenience 2∼3
Minor dosimetric error 4
Limited toxicity (may not require medical 5∼6
attention) or minor under-dose to PTV  
Potentially serious toxicity or injury 7∼8
(may require medical attention) or major  
under-dose to PTV  
Possible serious toxicities (requires medical 9
attention)  
Catastrophic 10
Table 3.
Probability that the failure mode resulting from the specific cause will go undetected.1)
Detection ability of failure mode in % Prob g ability that failure m oes undetected in % ode Ranking
99.99 0.01 1
99.80 0.20 2
99.50 0.50 3
99.00 1.00 4
98.00 2.00 5
95.00 5.00 6
90.00 10.00 7
85.00 15.00 8
80.00 20.00 9
Extreme likelihood >20.00 10
Table 4.
Errors in the CT simulation room in Yeungnam University Hospital.
오류 내용 O S D RPN
타겟 중심 설정의 오류 5 7 1 35
skin-marker 오류 5 5 1 25
고정기구 사용의 오류 5 3 4 60
환자 자세 설정의 오류 4 2 7 56
모의치료 정보입력의 오류 류 3 2 1 6

O: Occurrence, S: Severity, D: Lack of Detectability, RPN: Risk Priority Number (RPN: O×S×D).

Table 5.
Errors in the treatment planning room in Yeungnam University Hospital.
오류내용 O S D RPN
iso-center의 일치에 대한 오류 4 7 2 56
선량계산 모델 선택의 오류 3 8 7 168
비균질부위에 대한 보정의 오류 5 7 3 105
Dose/Fraction의 오류 5 8 2 80
Target coverage의 오류 5 8 2 80
OAR Dose의 오류 5 7 3 105
Global maximum의 위치 오류 6 6 4 144
Graticule의 오류 6 3 4 72
Bolus 오류 5 5 4 100
Plan/Fraction scheduling 오류 4 8 4 128
환자의 치료 시작일 오류 4 3 3 36

O: Occurrence, S: Severity, D: Lack of Detectability, RPN: Risk Priority Number (RPN: O×S×D).

Table 6.
Errors in the treatment room in Yeungnam University Hospital.
오류내용 O S D RPN
Pillow 오류 4 3 2 24
Tongue bite 오류 틀니 오류 6 6 5 5 3 3 90 90
틀니 오류 6 5 3 90
이름이 같은 다른 사람 치료의 오류 3 9 2 54
center를 이동하지 않은 오류 5 9 2 90
가발 오류 5 7 4 140
모자 오류 5 7 4 140
체중변화 오류 6 8 4 192
Lens shilding 위치 오류 6 9 3 162
Table Bar 오류 7 6 6 252
치료 횟수의 오류 4 9 2 72

O: Occurrence, S: Severity, D: Lack of Detectability, RPN: Risk Priority Number (RPN: O×S×D).

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