Accidental overexposure related to new radiation therapy technologies

Abstract

The aim of this review paper is to examine medical overexposure accidents related to new technologies in radiation therapy during the period 2000–2009. Reported radiation therapy overexposures from 2000 to 2009 were searched in English (mainly) and Japanese. Radiation therapy accidental overexposure incidents relating to new radiation therapy technology reported in the period 2000–2009 were included. Radiotherapy root causes of overexposure were classified into three main groups: “human-,” “system-,” and “equipment-” related errors. A total of 24 of the most serious radiation therapy overexposure accidents were reviewed. The accidents occurred most frequently in patients treated with 3D conformal radiation therapy (11) and stereotactic radiosurgery (7). The majority of the accidents were related to treatment planning procedure (8) and calibration (7) of new equipment or radiotherapy treatment planning system software, followed by accidents in treatment delivery (5), and treatment setup (4). The main causes of the accidents were related to human error—62.5% (15), equipment—29.2% (7), and system—8.3% (2). Several factors have been identified that can have a significant impact on reduction of the number of accidents related to the use of new radiation therapy technologies. These include thorough preparation and management of resources, such as having sufficient number of staff, adequate staff training, risk audits of new technology, quality assurance, and an enhanced safety culture.