1
|
Kornek D, Menichelli D, Leske J, Hofmann M, Antkiewicz D, Brandt T, Ott OJ, Lotter M, Lang-Welzenbach M, Fietkau R, Bert C. Development and clinical implementation of a digital system for risk assessments for radiation therapy. Z Med Phys 2024; 34:371-383. [PMID: 37666699 PMCID: PMC11384085 DOI: 10.1016/j.zemedi.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/06/2023]
Abstract
Before introducing new treatment techniques, an investigation of hazards due to unintentional radiation exposures is a reasonable activity for proactively increasing patient safety. As dedicated software is scarce, we developed a tool for risk assessment to design a quality management program based on best practice methods, i.e., process mapping, failure modes and effects analysis and fault tree analysis. Implemented as a web database application, a single dataset was used to describe the treatment process and its failure modes. The design of the system and dataset allowed failure modes to be represented both visually as fault trees and in a tabular form. Following the commissioning of the software for our department, previously conducted risk assessments were migrated to the new system after being fully re-assessed which revealed a shift in risk priorities. Furthermore, a weighting factor was investigated to bring risk levels of the migrated assessments into perspective. The compensation did not affect high priorities but did re-prioritize in the midrange of the ranking. We conclude that the tool is suitable to conduct multiple risk assessments and concomitantly keep track of the overall quality management activities.
Collapse
Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | | | - Jörg Leske
- IBA Dosimetry GmbH, 90592 Schwarzenbruck, Germany.
| | | | | | - Tobias Brandt
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Marga Lang-Welzenbach
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| |
Collapse
|
2
|
Wang L, Ding Y, Bruno TL, Stafford RJ, Lin E, Bathala TK, Sanders JW, Ning MS, Ma J, Klopp AH, Venkatesan A, Wang J, Martirosyan KS, Frank SJ. A Novel Positive-Contrast Magnetic Resonance Imaging Line Marker for High-Dose-Rate (HDR) MRI-Assisted Radiosurgery (MARS). Cancers (Basel) 2024; 16:1922. [PMID: 38792000 PMCID: PMC11119838 DOI: 10.3390/cancers16101922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 05/15/2024] [Accepted: 05/17/2024] [Indexed: 05/26/2024] Open
Abstract
Magnetic resonance imaging (MRI) can facilitate accurate organ delineation and optimal dose distributions in high-dose-rate (HDR) MRI-Assisted Radiosurgery (MARS). Its use for this purpose has been limited by the lack of positive-contrast MRI markers that can clearly delineate the lumen of the HDR applicator and precisely show the path of the HDR source on T1- and T2-weighted MRI sequences. We investigated a novel MRI positive-contrast HDR brachytherapy or interventional radiotherapy line marker, C4:S, consisting of C4 (visible on T1-weighted images) complexed with saline. Longitudinal relaxation time (T1) and transverse relaxation time (T2) for C4:S were measured on a 1.5 T MRI scanner. High-density polyethylene (HDPE) tubing filled with C4:S as an HDR brachytherapy line marker was tested for visibility on T1- and T2-weighted MRI sequences in a tissue-equivalent female ultrasound training pelvis phantom. Relaxivity measurements indicated that C4:S solution had good T1-weighted contrast (relative to oil [fat] signal intensity) and good T2-weighted contrast (relative to water signal intensity) at both room temperature (relaxivity ratio > 1; r2/r1 = 1.43) and body temperature (relaxivity ratio > 1; r2/r1 = 1.38). These measurements were verified by the positive visualization of the C4:S (C4/saline 50:50) HDPE tube HDR brachytherapy line marker on both T1- and T2-weighted MRI sequences. Orientation did not affect the relaxivity of the C4:S contrast solution. C4:S encapsulated in HDPE tubing can be visualized as a positive line marker on both T1- and T2-weighted MRI sequences. MRI-guided HDR planning may be possible with these novel line markers for HDR MARS for several types of cancer.
Collapse
Affiliation(s)
- Li Wang
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (L.W.); (E.L.)
| | - Yao Ding
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.D.); (J.W.)
| | - Teresa L. Bruno
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.L.B.); (M.S.N.); (A.H.K.)
| | - R. Jason Stafford
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.J.S.); (J.M.)
| | - Eric Lin
- Department of Experimental Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (L.W.); (E.L.)
| | - Tharakeswara K. Bathala
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.K.B.); (A.V.)
| | | | - Matthew S. Ning
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.L.B.); (M.S.N.); (A.H.K.)
| | - Jingfei Ma
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (R.J.S.); (J.M.)
| | - Ann H. Klopp
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.L.B.); (M.S.N.); (A.H.K.)
| | - Aradhana Venkatesan
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.K.B.); (A.V.)
| | - Jihong Wang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (Y.D.); (J.W.)
| | - Karen S. Martirosyan
- Department of Physics, The University of Texas Rio Grande Valley, Brownsville, TX 78500, USA;
| | - Steven J. Frank
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA; (T.L.B.); (M.S.N.); (A.H.K.)
| |
Collapse
|
3
|
Gates EDH, Wallner K, Tiwana J, Ford E, Phillips M, Lu L, Dumane V, Sheu RD, Kim M. Improved safety and quality in intravascular brachytherapy: A multi-institutional study using failure modes and effects analysis. Brachytherapy 2023; 22:779-789. [PMID: 37716819 DOI: 10.1016/j.brachy.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/20/2023] [Accepted: 07/27/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE Highlight safety considerations in intravascular brachytherapy (IVBT) programs, provide relevant quality assurance (QA) and safety measures, and establish their effectiveness. METHODS AND MATERIALS Radiation oncologists, medical physicists, and cardiologists from three institutions performed a failure modes and effects analysis (FMEA) on the radiation delivery portion of IVBT. We identified 40 failure modes and rated the severity, occurrence, and detectability before and after consideration of safety practices. Risk priority numbers (RPN) and relative risk rankings were determined, and a sample QA safety checklist was developed. RESULTS We developed a process map based on multi-institutional consensus. Highest-RPN failure modes were due to incorrect source train length, incorrect vessel diameter, and missing prior radiation history. Based on these, we proposed QA and safety measures: ten of which were not previously recommended. These measures improved occurrence and detectability: reducing the average RPN from 116 to 58 and median from 84 to 40. Importantly, the average RPN of the top 10% of failure modes reduced from 311 to 172. With QA considered, the highest risk failure modes were from contamination and incorrect source train length. CONCLUSIONS We identified several high-risk failure modes in IVBT procedures and practical safety and QA measures to address them.
Collapse
Affiliation(s)
- Evan D H Gates
- Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Kent Wallner
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Jasleen Tiwana
- Division of Cardiology, University of Washington, Seattle, WA
| | - Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Mark Phillips
- Department of Radiation Oncology, University of Washington, Seattle, WA
| | - Lan Lu
- Department of Radiation Oncology, Cleveland Clinic, Cleveland, OH
| | - Vishruta Dumane
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ren-Dih Sheu
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Minsun Kim
- Department of Radiation Oncology, University of Washington, Seattle, WA
| |
Collapse
|
4
|
Poder J, Rivard MJ, Howie A, Carlsson Tedgren Å, Haworth A. Risk and Quality in Brachytherapy From a Technical Perspective. Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00002-X. [PMID: 36682968 DOI: 10.1016/j.clon.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/23/2022] [Accepted: 01/04/2023] [Indexed: 01/15/2023]
Abstract
AIMS To provide an overview of the history of incidents in brachytherapy and to describe the pillars in place to ensure that medical physicists deliver high-quality brachytherapy. MATERIALS AND METHODS A review of the literature was carried out to identify reported incidents in brachytherapy, together with an evaluation of the structures and processes in place to ensure that medical physicists deliver high-quality brachytherapy. In particular, the role of education and training, the use of process and technical quality assurance and the role of international guidelines are discussed. RESULTS There are many human factors in brachytherapy procedures that introduce additional risks into the process. Most of the reported incidents in the literature are related to human factors. Brachytherapy-related education and training initiatives are in place at the societal and departmental level for medical physicists. Additionally, medical physicists have developed process and technical quality assurance procedures, together with international guidelines and protocols. Education and training initiatives, together with quality assurance procedures and international guidelines may reduce the risk of human factors in brachytherapy. CONCLUSION Through application of the three pillars (education and training; process control and technical quality assurance; international guidelines), medical physicists will continue to minimise risk and deliver high-quality brachytherapy treatments.
Collapse
Affiliation(s)
- J Poder
- Department of Radiation Oncology, St George Cancer Care Centre, Kogarah, New South Wales, Australia; School of Physics, University of Sydney, Camperdown, New South Wales, Australia; Centre for Medical Radiation Physics, University of Wollongong, Wollongong, New South Wales, Australia.
| | - M J Rivard
- Department of Radiation Oncology, Alpert Medical School of Brown University, Providence, RI, USA
| | - A Howie
- Department of Radiation Oncology, St George Cancer Care Centre, Kogarah, New South Wales, Australia
| | - Å Carlsson Tedgren
- Department of Health, Medicine and Caring Sciences (HMV), Radiation Physics, Linköping University, Linköping, Sweden; Medical Radiation Physics and Nuclear Medicine, The Karolinska University Hospital, Stockholm, Sweden; Department of Oncology Pathology, The Karolinska Institute, Stockholm, Sweden
| | - A Haworth
- School of Physics, University of Sydney, Camperdown, New South Wales, Australia
| |
Collapse
|
5
|
Quantifying clinical severity of physics errors in high-dose rate prostate brachytherapy using simulations. Brachytherapy 2021; 20:1062-1069. [PMID: 34193362 DOI: 10.1016/j.brachy.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/10/2021] [Accepted: 05/17/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE To quantitatively evaluate through automated simulations the clinical significance of potential high-dose rate (HDR) prostate brachytherapy (HDRPB) physics errors selected from our internal failure-modes and effect analysis (FMEA). METHODS AND MATERIALS A list of failure modes was compiled and scored independently by 8 brachytherapy physicists on a one-to-ten scale for severity (S), occurrence (O), and detectability (D), with risk priority number (RPN) = SxOxD. Variability of RPNs across observers (standard deviation/average) was calculated. Six idealized HDRPB plans were generated, and error simulations were performed: single (N = 1722) and systematic (N = 126) catheter shifts (craniocaudal; -1cm:1 cm); single catheter digitization errors (tip and connector needle-tips displaced independently in random directions; 0.1 cm:0.5 cm; N = 44,318); and swaps (two catheters swapped during digitization or connection; N = 528). The deviations due to each error in prostate D90%, urethra D20%, and rectum D1cm3 were analyzed using two thresholds: 5-20% (possible clinical impact) and >20% (potentially reportable events). RESULTS Twenty-nine relevant failure modes were described. Overall, RPNs ranged from 6 to 108 (average ± 1 standard deviation, 46 ± 23), with responder variability ranging from 19% to 184% (average 75% ± 30%). Potentially reportable events were observed in the simulations for systematic shifts >0.4 cm for prostate and digitization errors >0.3 cm for the urethra and >0.4 cm for rectum. Possible clinical impact was observed for catheter swaps (all organs), systematic shifts >0.2 cm for prostate and >0.4 cm for rectum, and digitization errors >0.2 cm for prostate and >0.1 cm for urethra and rectum. CONCLUSIONS A high variability in RPN scores was observed. Systematic simulations can provide insight in the severity scoring of multiple failure modes, supplementing typical FMEA approaches.
Collapse
|
6
|
Roles SA, Hepel JT, Leonard KL, Wazer DE, Cardarelli GA, Schwer ML, Saleh ZH, Klein EE, Brindle JM, Rivard MJ. Quantifying risk using FMEA: An alternate approach to AAPM TG-100 for scoring failures and evaluating clinical workflow. Brachytherapy 2021; 20:922-935. [PMID: 33840635 DOI: 10.1016/j.brachy.2021.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/26/2021] [Accepted: 02/12/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Renovation of the brachytherapy program at a leading cancer center utilized methods of the AAPM TG-100 report to objectively evaluate current clinical brachytherapy workflows and develop techniques for minimizing the risk of failures, increasing efficiency, and consequently providing opportunities for improved treatment quality. The TG-100 report guides evaluation of clinical workflows with recommendations for identifying potential failure modes (FM) and scoring them from the perspective of their occurrence frequency O, failure severity S, and inability to detect them D. The current study assessed the impact of differing methods to determine the risk priority number (RPN) beyond simple multiplication. METHODS AND MATERIALS The clinical workflow for a complex brachytherapy procedure was evaluated by a team of 15 staff members, who identified discrete FM using alternate scoring scales than those presented in the TG-100 report. These scales were expanded over all clinically relevant possibilities with care to emphasize mitigation of natural bias for scoring near the median range as well as to enhance the overall scoring-system sensitivity. Based on staff member perceptions, a more realistic measure of risk was determined using weighted functions of their scores. RESULTS This new method expanded the range of RPN possibilities by a factor of 86, improving evaluation and recognition of safe and efficient clinical workflows. Mean RPN values for each FM decreased by 44% when changing from the old to the new clinical workflow, as evaluated using the TG-100 method. This decreased by 66% when evaluated with the new method. As a measure of the total risk associated with an entire clinical workflow, the integral of RPN values increased by 15% and decreased by 31% with the TG-100 and new methods, respectively. CONCLUSIONS This appears to be the first application of an alternate approach to the TG-100 method for evaluating the risk of clinical workflows. It exemplifies the risk analysis techniques necessary to rapidly evaluate simple clinical workflows appropriately.
Collapse
Affiliation(s)
- Sean A Roles
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Jaroslaw T Hepel
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Kara L Leonard
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - David E Wazer
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Gene A Cardarelli
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michelle L Schwer
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Ziad H Saleh
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Eric E Klein
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - James M Brindle
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Mark J Rivard
- Department of Radiation Oncology, The Warren Alpert Medical School of Brown University, Providence, RI.
| |
Collapse
|
7
|
Muenkel J, Xu Z, Traughber BJ, Baig T, Xu K, Langmack C, Harris E, Podder TK. Feasibility of improving patient's safety with in vivo dose tracking in intracavitary and interstitial HDR brachytherapy. Brachytherapy 2020; 20:353-360. [PMID: 33187822 DOI: 10.1016/j.brachy.2020.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 08/29/2020] [Accepted: 09/14/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE The in vivo dosimetric monitoring in HDR brachytherapy is important for improving patient safety. However, there are very limited options available for clinical application. In this study, we present a new in vivo dose measurement system with a plastic scintillating detector (PSD) for GYN HDR brachytherapy. METHODS An FDA approved PSD system, called OARtrac (AngioDynamics, Latham, NY), was used with various applicators for in vivo dose measurements for GYN patients. An institutional workflow was established for the clinical implementation of the dosimetric system. Action levels were proposed based on the measurement and system uncertainty for measurement deviations. From October 2018 to September 2019, a total of 75 measurements (48 fractions) were acquired from 14 patients who underwent HDR brachytherapy using either a multichannel cylinder, Venezia applicator, or Syed-Neblett template. The PSDs were placed in predetermined catheters/channels. A planning CT was acquired for treatment planning in Oncentra (Elekta, Version-4.5.2) TPS. The PSDs were contoured on the CT images, and the PSD D90% values were used as the expected doses for comparison with the measured doses. RESULTS The mean difference from patient measurements was -0.22% ± 5.98%, with 26% being the largest deviation from the expected value (Syed case). Large deviations were observed when detectors were placed in the area where dose rates were less than 1 cGy/s. CONCLUSIONS The establishment of clinical workflow for the in vivo dosimetry for both the intracavitary and interstitial GYN HDR brachytherapy will potentially improve the safety of the patient treatment.
Collapse
Affiliation(s)
- Jessica Muenkel
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Zhengzheng Xu
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH.
| | - Bryan J Traughber
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH; School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Tanvir Baig
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Keying Xu
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Christian Langmack
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Eleanor Harris
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH; School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Tarun K Podder
- Department of Radiation Oncology, University Hospitals Cleveland Medical Center, Cleveland, OH; School of Medicine, Case Western Reserve University, Cleveland, OH
| |
Collapse
|
8
|
Rassiah P, Su FF, Huang YJ, Spitznagel D, Sarkar V, Szegedi MW, Zhao H, Paxton AB, Nelson G, Salter BJ. Using failure mode and effects analysis (FMEA) to generate an initial plan check checklist for improved safety in radiation treatment. J Appl Clin Med Phys 2020; 21:83-91. [PMID: 32583912 PMCID: PMC7484852 DOI: 10.1002/acm2.12918] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 04/14/2020] [Accepted: 04/28/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To apply failure mode and effect analysis (FMEA) to generate an effective and efficient initial physics plan checklist. METHODS A team of physicists, dosimetrists, and therapists was setup to reconstruct the workflow processes involved in the generation of a treatment plan beginning from simulation. The team then identified possible failure modes in each of the processes. For each failure mode, the severity (S), frequency of occurrence (O), and the probability of detection (D) was assigned a value and the risk priority number (RPN) was calculated. The values assigned were based on TG 100. Prior to assigning a value, the team discussed the values in the scoring system to minimize randomness in scoring. A local database of errors was used to help guide the scoring of frequency. RESULTS Twenty-seven process steps and 50 possible failure modes were identified starting from simulation to the final approved plan ready for treatment at the machine. Any failure mode that scored an average RPN value of 20 or greater was deemed "eligible" to be placed on the second checklist. In addition, any failure mode with a severity score value of 4 or greater was also considered for inclusion in the checklist. As a by-product of this procedure, safety improvement methods such as automation and standardization of certain processes (e.g., dose constraint checking, check tools), removal of manual transcription of treatment-related information as well as staff education were implemented, although this was not the team's original objective. Prior to the implementation of the new FMEA-based checklist, an in-service for all the second checkers was organized to ensure further standardization of the process. CONCLUSION The FMEA proved to be a valuable tool for identifying vulnerabilities in our workflow and processes in generating a treatment plan and subsequently a new, more effective initial plan checklist was created.
Collapse
Affiliation(s)
- Prema Rassiah
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | | | - Y. Jessica Huang
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | | | - Vikren Sarkar
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | - Martin W. Szegedi
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | - Hui Zhao
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | - Adam B. Paxton
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | - Geoff Nelson
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| | - Bill J. Salter
- Department of Radiation OncologyUniversity of UtahSalt Lake CityUTUSA
| |
Collapse
|
9
|
Clinical utility and value contribution of an MRI-positive line marker for image-guided brachytherapy in gynecologic malignancies. Brachytherapy 2020; 19:305-315. [DOI: 10.1016/j.brachy.2019.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 11/29/2019] [Accepted: 12/30/2019] [Indexed: 01/19/2023]
|
10
|
First experience of 192Ir source stuck event during high-dose-rate brachytherapy in Japan. J Contemp Brachytherapy 2020; 12:53-60. [PMID: 32190071 PMCID: PMC7073345 DOI: 10.5114/jcb.2020.92401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 12/09/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose To share the experience of an iridium-192 (192Ir) source stuck event during high-dose-rate (HDR) brachytherapy for cervical cancer. Material and methods In 2014, we experienced the first source stuck event in Japan when treating cervical cancer with HDR brachytherapy. The cause of the event was a loose screw in the treatment device that interfered with the gear reeling the source. This event had minimal clinical effects on the patient and staff; however, after the event, we created a normal treatment process and an emergency process. In the emergency processes, each staff member is given an appropriate role. The dose rate distribution calculated by the new Monte Carlo simulation system was used as a reference to create the process. Results According to the calculated dose rate distribution, the dose rates inside the maze, near the treatment room door, and near the console room were ≅ 10-2 [cGy · h-1], 10-3 [cGy · h-1], and << 10-3 [cGy · h-1], respectively. Based on these findings, in the emergency process, the recorder was evacuated to the console room, and the rescuer waited inside the maze until the radiation source was recovered. This emergency response manual is currently a critical workflow once a year with vendors. Conclusions We reported our experience of the source stuck event. Details of the event and proposed emergency process will be helpful in managing a patient safety program for other HDR brachytherapy users.
Collapse
|
11
|
Poirier Y, Johnstone CD, Anvari A, Brodin NP, Santos MD, Bazalova-Carter M, Sawant A. A failure modes and effects analysis quality management framework for image-guided small animal irradiators: A change in paradigm for radiation biology. Med Phys 2020; 47:2013-2022. [PMID: 31986221 DOI: 10.1002/mp.14049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 12/17/2019] [Accepted: 01/10/2020] [Indexed: 12/28/2022] Open
Abstract
PURPOSE Image-guided small animal irradiators (IGSAI) are increasingly being adopted in radiation biology research. These animal irradiators, designed to deliver radiation with submillimeter accuracy, exhibit complexity similar to that of clinical radiation delivery systems, including image guidance, robotic stage motion, and treatment planning systems. However, physics expertise and resources are scarcer in radiation biology, which makes implementation of conventional prescriptive QA infeasible. In this study, we apply the failure modes and effect analysis (FMEA) popularized by the AAPM task group 100 (TG-100) report to IGSAI and radiation biological research. METHODS Radiation biological research requires a change in paradigm where small errors to large populations of animals are more severe than grievous errors that only affect individuals. To this end, we created a new adverse effects severity table adapted to radiation biology research based on the original AAPM TG-100 severity table. We also produced a process tree which outlines the main components of radiation biology studies performed on an IGSAI, adapted from the original clinical IMRT process tree from TG-100. Using this process tree, we created and distributed a preliminary survey to eight expert IGSAI operators in four institutions. Operators rated proposed failure modes for occurrence, severity, and lack of detectability, and were invited to share their own experienced failure modes. Risk probability numbers (RPN) were calculated and used to identify the failure modes which most urgently require intervention. RESULTS Surveyed operators indicated a number of high (RPN >125) failure modes specific to small animal irradiators. Errors due to equipment breakdown, such as loss of anesthesia or thermal control, received relatively low RPN (12-48) while errors related to the delivery of radiation dose received relatively high RPN (72-360). Errors identified could either be improved by manufacturer intervention (e.g., electronic interlocks for filter/collimator) or physics oversight (errors related to tube calibration or treatment planning system commissioning). Operators identified a number of failure modes including collision between the collimator and the stage, misalignment between imaging and treatment isocenter, inaccurate robotic stage homing/translation, and incorrect SSD applied to hand calculations. These were all relatively highly rated (90-192), indicating a possible bias in operators towards reporting high RPN failure modes. CONCLUSIONS The first FMEA specific to radiation biology research was applied to image-guided small animal irradiators following the TG-100 methodology. A new adverse effects severity table and a process tree recognizing the need for a new paradigm were produced, which will be of great use to future investigators wishing to pursue FMEA in radiation biology research. Future work will focus on expanding scope of user surveys to users of all commercial IGSAI and collaborating with manufacturers to increase the breadth of surveyed expert operators.
Collapse
Affiliation(s)
- Yannick Poirier
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christopher Daniel Johnstone
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Physics and Astronomy, University of Victoria, Victoria, BC, Canada
| | - Akbar Anvari
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - N Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Morgane Dos Santos
- Service de Recherche en Radiobiologie et en Médecine régénérative, Laboratoire de Radiobiologie des expositions Accidentelles, Institut de Radioprotection et de Sûreté Nucléaire (IRSN), Fontenay-aux-Roses, France
| | | | - Amit Sawant
- Department of Radiation Oncology, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
12
|
Belley MD, Craciunescu O, Chang Z, Langloss BW, Stanton IN, Yoshizumi TT, Therien MJ, Chino JP. Real-time dose-rate monitoring with gynecologic brachytherapy: Results of an initial clinical trial. Brachytherapy 2018; 17:1023-1029. [DOI: 10.1016/j.brachy.2018.07.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 06/10/2018] [Accepted: 07/16/2018] [Indexed: 12/25/2022]
|
13
|
A risk-based approach to development of ultrasound-based high-dose-rate prostate brachytherapy quality management. Brachytherapy 2018; 17:788-793. [DOI: 10.1016/j.brachy.2018.05.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/15/2018] [Accepted: 05/23/2018] [Indexed: 11/22/2022]
|
14
|
Automated calculation of point A coordinates for CT-based high-dose-rate brachytherapy of cervical cancer. J Contemp Brachytherapy 2017; 9:354-358. [PMID: 28951755 PMCID: PMC5611457 DOI: 10.5114/jcb.2017.69397] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/12/2017] [Indexed: 11/29/2022] Open
Abstract
Purpose The goal is to develop a stand-alone application, which automatically and consistently computes the coordinates of the dose calculation point recommended by the American Brachytherapy Society (i.e., point A) based solely on the implanted applicator geometry for cervical cancer brachytherapy. Material and methods The application calculates point A coordinates from the source dwell geometries in the computed tomography (CT) scans, and outputs the 3D coordinates in the left and right directions. The algorithm was tested on 34 CT scans of 7 patients treated with high-dose-rate (HDR) brachytherapy using tandem and ovoid applicators. A single experienced user retrospectively and manually inserted point A into each CT scan, whose coordinates were used as the “gold standard” for all comparisons. The gold standard was subtracted from the automatically calculated points, a second manual placement by the same experienced user, and the clinically used point coordinates inserted by multiple planners. Coordinate differences and corresponding variances were compared using nonparametric tests. Results Automatically calculated, manually placed, and clinically used points agree with the gold standard to < 1 mm, 1 mm, 2 mm, respectively. When compared to the gold standard, the average and standard deviation of the 3D coordinate differences were 0.35 ± 0.14 mm from automatically calculated points, 0.38 ± 0.21 mm from the second manual placement, and 0.71 ± 0.44 mm from the clinically used point coordinates. Both the mean and standard deviations of the 3D coordinate differences were statistically significantly different from the gold standard, when point A was placed by multiple users (p < 0.05) but not when placed repeatedly by a single user or when calculated automatically. There were no statistical differences in doses, which agree to within 1-2% on average for all three groups. Conclusions The study demonstrates that the automated algorithm calculates point A coordinates consistently, while reducing inter-user variability. Point placement using the algorithm expedites the planning process and minimizes associated potential human errors.
Collapse
|
15
|
Commissioning of applicator-guided stereotactic body radiation therapy boost with high-dose-rate brachytherapy for advanced cervical cancer using radiochromic film dosimetry. Brachytherapy 2017; 16:893-902. [PMID: 28457741 DOI: 10.1016/j.brachy.2017.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/21/2017] [Accepted: 03/21/2017] [Indexed: 11/21/2022]
Abstract
PURPOSE To describe an EBT3 GAFCHROMIC film-based dosimetry method to be used in commissioning of a combined HDR brachytherapy (HDRB) and stereotactic body radiation therapy (SBRT) boost for treatment of advanced cervical cancer involving extensive residual disease after external beam treatment. METHODS AND MATERIALS A cube phantom was designed to firmly fit an intrauterine tandem applicator and EBT3 radiochromic film pieces. A high-risk clinical target volume (CTVHR, Total) was contoured with an extended arm at one side. The HDRB treatment was planned to cover the proximal CTVHR, Total with 7 Gy and the distal volume, referred to as CTVHR, Distal, was planned by SBRT for dose augmentation. After HDRB treatment delivery, SBRT treatment was delivered within 1 hour by image guidance using the applicator geometry. Intentional 1D and 2D misalignments were introduced to evaluate the effect on target volumes. In addition, effect of film reirradiation at different time gaps and dose levels was evaluated. RESULTS Film dosimetric accuracy, with up to 2 hours gap between irradiations, was shown to be unaffected. A 2%/2 mm gamma analysis between measured and planned doses showed agreement of >99%. Misalignments of more than 2 mm between applicator and SBRT isocenter resulted in suboptimal dose-volume histogram affecting mostly D98% and D90% of CTVHR, Distal. CONCLUSIONS Visualizing how target dose-volume metrics are affected by minor misalignments between SBRT and HDRB dose gradients, in light of achievable phantom-based experimental quality assurance level, encourages the clinical applicability of this technique. Radiochromic film was shown to be a valuable tool to commission procedures combining two different treatment planning systems and modalities with varying dose rates and energy ranges.
Collapse
|