eISSN: 2081-2841
ISSN: 1689-832X
Journal of Contemporary Brachytherapy
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4/2022
vol. 14
 
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abstract:
Original paper

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

1.
Division of Radiation Oncology, Department of Radiology, Faculty of Medicine, Siriraj Hospital, Thailand
J Contemp Brachytherapy 2022; 14, 4: 390–397
Online publish date: 2022/08/17
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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:

high-dose-rate brachytherapy, incidents reporting, incidents review, RT events, patient safety

 
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