Abstract
Radiotherapy is the only application of radiation which intentionally delivers very high doses to humans. A gross deviation from the prescribed dose or dose distribution can have severe, or even fatal consequences. Since the patient is placed directly in the beam or sources are inserted in the body, any mistake made with the beam or the sources leads almost certainly to an accidental exposure. Lessons learned from previous incidents can be used to test the vulnerability of a given facility, provided that these are adequately disseminated. The purpose of this paper is to present a summary of the lessons learned from a relatively large sample of events. The analysis has been presented as a short description followed by an identification of the triggering event and the contributing factors. These have been grouped as follows: errors in commissioning or calibration machines and sources affecting many patients; mistakes affecting individual patients such as irradiating the wrong patient, the wrong, field or site, and mistakes when entering data into or reading from the patient`s chart; error due to unusual treatments or situations; equipment failure and human machine problems, including maintenance. (author). 1 ref.
Ortiz-Lopez, P;
[1]
Novotny, J;
[2]
Haywood, J
[3]
- International Atomic Energy Agency, Vienna (Austria). Div. of Nuclear Safety
- University Hospital St. Rafael, Leuven (Belgium)
- South Cleveland Hospital (United Kingdom). Cleveland Medical Physics Unit
Citation Formats
Ortiz-Lopez, P, Novotny, J, and Haywood, J.
Lessons learned from accidents in radiotherapy.
IAEA: N. p.,
1996.
Web.
Ortiz-Lopez, P, Novotny, J, & Haywood, J.
Lessons learned from accidents in radiotherapy.
IAEA.
Ortiz-Lopez, P, Novotny, J, and Haywood, J.
1996.
"Lessons learned from accidents in radiotherapy."
IAEA.
@misc{etde_429942,
title = {Lessons learned from accidents in radiotherapy}
author = {Ortiz-Lopez, P, Novotny, J, and Haywood, J}
abstractNote = {Radiotherapy is the only application of radiation which intentionally delivers very high doses to humans. A gross deviation from the prescribed dose or dose distribution can have severe, or even fatal consequences. Since the patient is placed directly in the beam or sources are inserted in the body, any mistake made with the beam or the sources leads almost certainly to an accidental exposure. Lessons learned from previous incidents can be used to test the vulnerability of a given facility, provided that these are adequately disseminated. The purpose of this paper is to present a summary of the lessons learned from a relatively large sample of events. The analysis has been presented as a short description followed by an identification of the triggering event and the contributing factors. These have been grouped as follows: errors in commissioning or calibration machines and sources affecting many patients; mistakes affecting individual patients such as irradiating the wrong patient, the wrong, field or site, and mistakes when entering data into or reading from the patient`s chart; error due to unusual treatments or situations; equipment failure and human machine problems, including maintenance. (author). 1 ref.}
place = {IAEA}
year = {1996}
month = {Aug}
}
title = {Lessons learned from accidents in radiotherapy}
author = {Ortiz-Lopez, P, Novotny, J, and Haywood, J}
abstractNote = {Radiotherapy is the only application of radiation which intentionally delivers very high doses to humans. A gross deviation from the prescribed dose or dose distribution can have severe, or even fatal consequences. Since the patient is placed directly in the beam or sources are inserted in the body, any mistake made with the beam or the sources leads almost certainly to an accidental exposure. Lessons learned from previous incidents can be used to test the vulnerability of a given facility, provided that these are adequately disseminated. The purpose of this paper is to present a summary of the lessons learned from a relatively large sample of events. The analysis has been presented as a short description followed by an identification of the triggering event and the contributing factors. These have been grouped as follows: errors in commissioning or calibration machines and sources affecting many patients; mistakes affecting individual patients such as irradiating the wrong patient, the wrong, field or site, and mistakes when entering data into or reading from the patient`s chart; error due to unusual treatments or situations; equipment failure and human machine problems, including maintenance. (author). 1 ref.}
place = {IAEA}
year = {1996}
month = {Aug}
}