Radiation safetyThe use of human factors methods to identify and mitigate safety issues in radiation therapy
Section snippets
Material and methods
This study was conducted at Princess Margaret Hospital (PMH) in Ontario, Canada. PMH is staffed with approximately 150 radiation therapists and is equipped with 16 linear accelerators. This study focused on the Synergy® linear accelerator system manufactured by Elekta (Elekta Medical Systems, Crawley, UK). This system was controlled with the Desktop ProTM 7 control system, in conjunction with MOSAIQTM (IMPAC Medical Systems, Sunnyvale, CA), a R&V system.
To investigate potential issues with the
Results
Based on findings from the field observations and workflow analysis, the area that was found to be of particular concern was the checking process performed by radiation therapists prior to treatment delivery. At PMH, radiation therapists are required by policy to perform many checks to minimize the potential for use errors. These include checking the approval status of the treatment plan and the planning images, verifying the setup iso-center with the planning images, and verifying the linear
Discussion
Based on our findings from field observations and workflow analysis, the checking process during patient setup was found to be an area associated with many human factors issues. A number of studies from the literature have also shown that it is common behavior for health professionals to omit checks when not reinforced [33], [34]. This is particularly true when there are interruptions or distractions [35], [36]. Occasionally, radiation therapists would also omit some of the required checks,
Conflict of interest statement
There is no known conflict of interest.
Acknowledgements
This study was funded by the Natural Sciences and Engineering Research Council of Canada, the Canadian Patient Safety Institute, the National Patient Safety Foundation, and The American Association of Physicists in Medicine. The authors wish to thank Elekta for providing information on its products, as well as Catherine Dupuis from Princess Margaret Hospital and Varuna Prakash from the University of Toronto for their invaluable contributions to this study.
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