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.