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. 2022 Aug;14(4):390-397.
doi: 10.5114/jcb.2022.118793. Epub 2022 Aug 17.

Patient safety program and incident review of high-dose-rate brachytherapy at an academic center in Thailand

Lalida Tuntipumiamorn  1 , Kanitta Kamplong  1 , Bhuvadol Pengchantr  1 , Kantarat Rojanapan  1 , Porntip Iampongpaiboon  1 , Yaowalak Chansilpa  1
Affiliations

Patient safety program and incident review of high-dose-rate brachytherapy at an academic center in Thailand

Lalida Tuntipumiamorn et al. J Contemp Brachytherapy. 2022 Aug.

Abstract

Purpose: An incident review of errors related to using high-dose-rate brachytherapy (HDR-BT) and associated patient safety program were presented. This study was based on 9 years' experience using VariSource afterloader system.

Material and methods: Analysis was made on radiotherapy (RT) incidents (including near-misses) that were routinely recorded using manual and electronic incident reporting systems between July 2012 and December 2021. Each incident's origin was categorized as 'apparatus', 'system functionality', 'treatment procedure', and 'other causes'.

Results: From 8,100 fractions and 2,216 patients, there were 164 RT incidents. The most frequent cases included non-dosimetric errors arising from system malfunction (49/151), difficulties caused by insufficient instruments (47/151), problems with treatment delivery (55/151), and planning procedure errors (13/142). Eleven incidents were near-misses, another 11 were not harmful, and zero were harmful. The frequency rate of dosimetric errors was 0.14 per 100 BT insertions, and 0.5 per 100 patients. The review also discovered 45 of the 164 incidents related to tube sensor failures and source blockages. These delivery errors were associated with 0.56 incidents per 100 insertions and 2.03 incidents per 100 patients, inconveniencing patients in treatment delays.

Conclusions: The effectiveness of our HDR-BT safety program was evidenced by low-rate of dosimetric errors. Based on the analysis of 9 years of incidents, the error sources included uncommon or complex procedures, human factors, and work environment (equipment availability and maintenance).

Keywords: RT events; high-dose-rate brachytherapy; incidents reporting; incidents review; patient safety.

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Conflict of interest statement

The authors report no conflict of interest.

Figures

Fig. 1
Fig. 1
Communication sheet for transferring and receiving treatment details between team members
Fig. 2
Fig. 2
Reported RT incidents over time by event type
See this image and copyright information in PMC

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