1F03-Human Errors and impacts on Radiotherapy Quality

Raymond K. Wu, PhD

OhioHealth Hospitals

3535 Olentangy River Road

Columbus, OH 43214

To err is human, but if the error impacts on a radiation therapy patient, it is considered unacceptable.  With the advent of sophisticated techniques, high spatial precision in beam delivery, and escalating prescribed dose, the potential risks in harming the patient are even higher when mistakes are made.  In this talk the full spectrum of human errors will be considered.  At one end of the spectrum, several well documented errors in radiotherapy are analyzed and the subsequent corrective measures implemented at governmental levels are described.  At the other end of the spectrum, common errors occurring in radiotherapy facilities across the country were collected, categorized and will be presented.  The characteristics of errors commonly seen today are compared with those of fifteen years ago.  Based on the accepted risks for daily activities and risks for activities in industrial environments, error-rate limits for radiotherapy treatments had been proposed.  Methods to document the errors, to assure errors are reported, and to derive the most benefit from the errors will be presented.  Effective ways to reduce error rates to levels well below the proposed limits will be described. The government regulator’s role will be proposed.  The importance of the medical physicist to take ownership for error reduction or eradication will be emphasized.

1F03-人为过失及其对放疗质量的影响

Raymond K. Wu, PhD

OhioHealth Hospitals

3535 Olentangy River Road

Columbus, OH 43214

人都会犯错误，但是若犯的错误影响了对放疗病患者的治疗，则是不可接受的。随着复杂技术的出现、治疗辐射线瞄准精度的提高、以及处方剂量的增加，出现错误将会给患者带来更大伤害。本讲全面讲述各种人为过失引起的误差。对几个记录完整的放疗事故进行分析，并介绍事发后各级政府所采取的弥补措施。我们收集了各地放疗设备的常见事故，在这里进行分类阐述。对现在和15年前的常见事故特点进行比较。以日常生活已被接受的风险，和各种职业环境的风险作依据，放疗事故率的限值已有文献提出建议。本讲将阐述事故记录的方法、如何保证事故发生时不被蒙蔽、并能从事故中汲取经验教训。本讲并介绍减小事故率达到上述文献限值以下的有效方法。对政府管理者的责任提出建议。强调医学物理师拥有减少、消除事故的责任感的重要性。