Facilitation of radiotherapeutic error by computerized record and verify systems

• Published in: International journal of radiation oncology, biology, physics Vol. 56; no. 1; pp. 50 - 57
• Main Authors: Patton, Gregory A, Gaffney, David K, Moeller, John H
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.05.2003; Elsevier
• Subjects: Adenocarcinoma - radiotherapy; Adenocarcinoma - secondary; Biological and medical sciences; Breast Neoplasms - radiotherapy; Breast Neoplasms - surgery; Carcinoma - radiotherapy; Equipment Failure; Error; Female; Forms and Records Control; Humans; Linear accelerators; Lymphatic Irradiation; Lymphatic Metastasis - radiotherapy; Male; Mathematics; Medical Errors - classification; Medical Errors - prevention & control; Medical Errors - statistics & numerical data; Medical Records Systems, Computerized; Medical sciences; Particle Accelerators; Patient Identification Systems; Pelvic Neoplasms - radiotherapy; Pelvic Neoplasms - secondary; Prostatic Neoplasms - radiotherapy; Radiation Injuries - etiology; Radiation Injuries - prevention & control; Radiotherapy; Radiotherapy Dosage; Radiotherapy, Computer-Assisted; Radiotherapy, Conformal; Radiotherapy, High-Energy - instrumentation; Record and verify; Retrospective Studies; Utah; Utah; Error; Radiotherapy; Record and verify; Linear accelerators
• ISSN: 0360-3016; 1879-355X
• DOI: 10.1016/S0360-3016(02)04418-8

To examine the impact of computerized record and verify (R&V) systems on types of radiotherapeutic error. Radiation therapy treatment errors reported by therapists at the University of Utah between July 1, 1999 and June 30, 2000 were retrospectively reviewed. During a 1-year period in which 22,542 external beam radiation therapy treatments were administered, 38 treatment errors (representing 0.17% of external beam treatments administered during this period) were identified and reviewed. Nine cases (0.04% of treatments) representing four types of record and verify (R&V)-related errors were identified, in which the department’s R&V system played a contributory role in the treatment error. The common denominator among these R&V-related errors was excessive reliance upon the computer system by therapists. R&V systems eliminate some, but not all, pathways of radiotherapeutic error. Although R&V systems have assumed a crucial role in the precise and reproducible delivery of increasingly complex radiation therapy treatments, their inability to eradicate all radiotherapeutic errors coupled with their parallel ability to facilitate certain mistakes mandates vigilance on the part of the radiation therapy team. Radiation therapy treatment procedures must preserve careful oversight of R&V functions to minimize prospects for treatment error.