Browse > Article
http://dx.doi.org/10.3857/roj.2013.31.2.88

Categorizing accident sequences in the external radiotherapy for risk analysis  

Kim, Jonghyun (KEPCO International Nuclear Graduate School (KINGS))
Publication Information
Radiation Oncology Journal / v.31, no.2, 2013 , pp. 88-96 More about this Journal
Abstract
Purpose: This study identifies accident sequences from the past accidents in order to help the risk analysis application to the external radiotherapy. Materials and Methods: This study reviews 59 accidental cases in two retrospective safety analyses that have collected the incidents in the external radiotherapy extensively. Two accident analysis reports that accumulated past incidents are investigated to identify accident sequences including initiating events, failure of safety measures, and consequences. This study classifies the accidents by the treatments stages and sources of errors for initiating events, types of failures in the safety measures, and types of undesirable consequences and the number of affected patients. Then, the accident sequences are grouped into several categories on the basis of similarity of progression. As a result, these cases can be categorized into 14 groups of accident sequence. Results: The result indicates that risk analysis needs to pay attention to not only the planning stage, but also the calibration stage that is committed prior to the main treatment process. It also shows that human error is the largest contributor to initiating events as well as to the failure of safety measures. This study also illustrates an event tree analysis for an accident sequence initiated in the calibration. Conclusion: This study is expected to provide sights into the accident sequences for the prospective risk analysis through the review of experiences.
Keywords
Risk assessment; Accident; Radiotherapy; Safety;
Citations & Related Records
연도 인용수 순위
  • Reference
1 Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer 2005;104:1129-37.   DOI
2 World Health Organization. Radiotherapy risk profile. Geneva, Switzerland: World Health Organization; 2008.
3 Task Group on Accident Prevention and Safety in Radiation Therapy. Prevention of accidental exposures to patients undergoing radiation therapy: a report of the International Commission on Radiological Protection. Ann ICRP 2000;30:7-70.
4 Wreathall J, Nemeth C. Assessing risk: the role of probabilistic risk assessment (PRA) in patient safety improvement. Qual Saf Health Care 2004;13:206-12.   DOI
5 Lee JC, McCormick NJ. Risk and safety analysis of nuclear systems. Hoboken, NJ: John Wiley & Sons; 2011.
6 International Atomic Energy Agency. Lessons learned from accidental exposures in radiotherapy (safety reports series 17). Vienna, Austria: International Atomic Energy Agency; 2000.
7 Ortiz Lopez P, Cosset JM, Dunscombe P, et al. ICRP publication 112: a report of preventing accidental exposures from new external beam radiation therapy technologies. Ann ICRP 2009;39:1-86.
8 Swain AD, Guttmann HE; US Nuclear Regulatory Commission. Handbook of human reliability analysis with emphasis on nuclear power plant applications. Washington, DC: US Nuclear Regulatory Commission; 1983.
9 Lyons M, Adams S, Woloshynowych M, Vincent C. Human reliability analysis in healthcare: a review of techniques. Int J Risk Saf Med 2004;16;223-37.