Collection and evaluation of incidents in a radiotherapy department : a reactive risk analysis

Abstract

Purpose: to report on the use of an internal system for incident reporting.

Patients and methods: from October 2001 until June 2009, data on incidents were collected in the radiotherapy department (RT) by means of an incident reporting worksheet. The risk analysis was based on the US Navy method of mishap cause investigation, the Human Factors Analysis and Classification System (HFACS).

Results: 37 incidents over 5,635 treatments were collected. Of the incidents, 20 involved deviation of the dose to the patient; only 6 showed clinical evidence of overdosage, while 2 of them showed permanent evidence of overdosage. There were 24 incidents that were classified as near misses (NM). Incorrect data input and use of an incorrect treatment field were the most common causes of the registered incidents. Reactive risk analysis showed how skill-based errors were associated with attention failure at the unsafe act level. Dose prescription and dose calculation are the most critical phases of the entire process. Most of the errors were discovered in set-up/treatment and during treatment visit/follow-up phases. The highest number of correction procedures was necessary in the phases of dose prescription and dose calculation.

Conclusion: collecting and analyzing internal incidents improves the operative procedures used in the department.