A Four-Year Survey of Error Reports In A Radiotherapy Department

Abstract

Ebrahim Esmati, Nafise Hasoomi*, Asma Khodadadi, Neda Maal Andish, Reza Ghalehtak, Ali Kazemian

Purpose

Patient safety is a fundamental concept in radiotherapy due to the delivery of large radiation doses in a single frac- tion. Radiotherapy is a highly complex procedure with many steps, which confers a high risk of errors. This study aimed to investigate radiotherapy errors and their effects on patients to provide a framework for increasing our knowledge of radiotherapy, quality of treatment and patient safety.

Materials and Methods

The total number of error reports was 648 during four years of this survey (2017-2020), 51% of which were attributed to near-misses, and the patients were not affected by the errors. Also, 40% of the errors were incident errors, while the rest were non-conformity errors. Meanwhile, the number of treatment courses was 12,755, 32,118, 34,052, and 39,784 throughout the survey during 2017-2020, respectively.

Results

The annual error ratio was 2.2 in 100 treatment courses. Use of a collaborative interprofessional approach led to a decrease in the incident errors by 20% and an increase in near-misses by 24% during the survey (P=.002).

Conclusion

Our outcomes indicated that analyzing radiotherapy errors and their effects on patients can help radiotherapy teams, including radiation oncologists, physicists, and radiation therapists, to provide the best services for the patients; it also improves teamwork and increases the quality of treatment.

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