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Holmberg O, Pinak M. How often does it happen? A review of unintended, unnecessary and unavoidable high-dose radiation exposures. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2021; 41:R189-R201. [PMID: 34157693 DOI: 10.1088/1361-6498/ac0d64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/22/2021] [Indexed: 06/13/2023]
Abstract
High-dose radiation exposures of humans occur every year around the world, and may lead to harmful tissue reactions. This review aims to look at the available information sources that can help answering the question of how often these events occur yearly on a global scale. In the absence of comprehensive databases of global occurrence, publications on radiation accidents in all uses of radiation and on rates of high-dose events in different medical uses of radiation have been reviewed. Most high-dose radiation exposures seem to occur in the medical uses of radiation, reflecting the high number of medical exposures performed. In therapeutic medical uses, radiation doses are purposely often given at levels known to cause deterministic effects, and there is a very narrow range in which the medical practitioner can operate without causing severe unacceptable outcomes. In interventional medical uses, there are scenarios in which the radiation dose given to a patient may reach or exceed a threshold for skin effects, where this radiation dose may be unavoidable, considering all benefits and risks as well as benefits and risks of any alternative procedures. Regardless of if the delivered dose is unintended, unnecessary or unavoidable, there are estimates published of the rates of high-dose events and of radiation-induced tissue injuries occurring in medical uses. If this information is extrapolated to a global scenario, noting the inherent limitations in doing so, it does not seem unreasonable to expect that the global number of radiation-induced injuries every year may be in the order of hundreds, likely mainly arising from medical uses of radiation, and in particular from interventional fluoroscopy procedures and external beam radiotherapy procedures. These procedures are so frequently employed throughout the world that even a very small rate of radiation-induced injuries becomes a substantial number when scaled up to a global level.
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Affiliation(s)
- Ola Holmberg
- Radiation Protection of Patients Unit, International Atomic Energy Agency, Vienna, Austria
| | - Miroslav Pinak
- Radiation Safety and Monitoring Section, International Atomic Energy Agency, Vienna, Austria
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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.
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Sanders JC, Showalter TN, Ouhib Z, Thomadsen BR, Jacob D, Agarwal M, Cohen GN, Giles M, Palaniswammy G, Solanki AA, Taunk NK. Safety practices and opportunities for improvement in brachytherapy: A patient safety practices survey of the American Brachytherapy Society membership. Brachytherapy 2020; 19:762-766. [PMID: 32952055 DOI: 10.1016/j.brachy.2020.08.014] [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: 05/25/2020] [Revised: 07/14/2020] [Accepted: 08/11/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Safe delivery of brachytherapy and establishing a safety culture are critical in high-quality brachytherapy. The American Brachytherapy Society (ABS) Quality and Safety Committee surveyed members regarding brachytherapy services offered, safety practices during treatment, quality assurance procedures, and needs to develop safety and training materials. METHODS AND MATERIALS A 22-item survey was sent to ABS membership in early 2019 to physicians, physicists, therapists, nurses, and administrators. Participation was voluntary. Responses were summarized with descriptive statistics and relative frequency distributions. RESULTS There were 103 unique responses. Approximately one in three was attending physicians and one in three attending physicists. Most were in practice >10 years. A total of 94% and 50% performed gynecologic and prostate brachytherapy, respectively. Ninety-one percent performed two-identification patient verification before treatment. Eighty-six percent performed a time-out. Ninety-five percent had an incident reporting or learning system, but only 71% regularly reviewed incidents. Half reviewed safety practices within the last year. Twenty percent reported they were somewhat or not satisfied with department safety culture, but 92% of respondents were interested in improving safety culture. Most reported time, communication, and staffing as barriers to improving safety. Most respondents desired safety-oriented webinars, self-assessment modules, learning modules, or checklists endorsed by the ABS to improve safety practice. CONCLUSIONS Most but not all practices use standards and quality assurance procedures in line with society recommendations. There is a need to heighten safety culture at many departments and to shift resources (e.g., time or staffing) to improve safety practice. There is a desire for society guidance to improve brachytherapy safety practices. This is the first survey to assess safety practice patterns among a national sample of radiation oncologists with expertise in brachytherapy.
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Affiliation(s)
- Jason C Sanders
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Zoubir Ouhib
- Department of Radiation Oncology, Lynn Cancer Institute, Boca Raton, FL
| | | | - Dayee Jacob
- Department of Radiation Oncology, Christiana Care Health System, Wilmington, DE
| | - Manuj Agarwal
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matt Giles
- Department of Radiation Oncology, Winship Cancer Institute, Emory St. Joseph's Hospital, Atlanta, GA
| | | | - Abhishek A Solanki
- Department of Radiation Oncology, Loyola University Chicago, Stritch School of Medicine, Maywood, IL
| | - Neil K Taunk
- Department of Radiation Oncology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA.
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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.
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Huynh-Le MP, Simon AB, Hoopes DJ, Einck JP, Yashar CM, Scanderbeg D, Rash D, Brown D, Mell LK, Sanghvi PR, Mundt AJ, Pawlicki T, Mayadev JS. Implementation of peer-review quality rounds for gynecologic brachytherapy in a high-volume academic center. Brachytherapy 2020; 19:881-888. [PMID: 31917179 DOI: 10.1016/j.brachy.2019.11.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 11/19/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE While peer review is critical for quality and safety in radiotherapy, there are neither formal guidelines nor format examples for brachytherapy (BT) peer review. We report on a gynecologic BT peer-review method implemented at a high-volume academic center. METHODS AND MATERIALS We analyzed discussions at bimonthly gynecologic BT peer-review rounds between July and December 2018. Rounds consisted of 2-5 attending physicians with gynecologic BT expertise, 1-2 BT physicists, and trainees. Peer-review targets included clinical case review, contours, implant technique, dose/fractionation, and target/organ-at-risk (OAR) dosimetry. The projected/final target and OAR dosimetry were analyzed. RESULTS 55 separate implants from 44 patients were reviewed. Implants were mostly reviewed after the first BT fraction (n = 16, 29%) or at another time point during BT (n = 20, 36%). One (2%) implant was presented prospectively. The applicator type and BT technique were reviewed for all implants. Dose/fractionation was evaluated for 46 implants (84%); contours were discussed for 21 (38%). Target and OAR dosimetry were reviewed for 54 (98%) and 28 implants (51%), respectively. Six cases (11%) underwent minor changes to the applicator type to improve target and/or OAR dosimetry. One case (2%) had a major change recommended to the dose/fractionation. CONCLUSIONS Gynecologic BT peer review may enhance BT quality by allowing for implant optimization and formal review of challenging cases, ultimately improving medical decision-making and team communication. Peer review should be implemented in centers offering gynecologic BT.
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Affiliation(s)
- Minh-Phuong Huynh-Le
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Aaron B Simon
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - David J Hoopes
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - John P Einck
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Catheryn M Yashar
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Daniel Scanderbeg
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Dominique Rash
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Derek Brown
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Loren K Mell
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Parag R Sanghvi
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Todd Pawlicki
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Jyoti S Mayadev
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA.
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Kallis K, Ziegler M, Lotter M, Kreppner S, Strnad V, Fietkau R, Bert C. Is adaptive treatment planning in multi-catheter interstitial breast brachytherapy necessary? Radiother Oncol 2019; 141:304-311. [PMID: 31530431 DOI: 10.1016/j.radonc.2019.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/14/2019] [Accepted: 08/17/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE For 55 patients treated with interstitial multi-catheter breast brachytherapy the need for adaptive treatment planning was assessed. METHODS AND MATERIALS For all patients a treatment planning computed tomography (CT) and a follow-up CT were acquired and used for the retrospective evaluation. Keeping dwell time and dwell positions constant, the treatment plan assessed directly after catheter implantation was compared to the situation 48 h after implantation. Both manual catheter reconstructions, based on the planning and follow-up CT, were rigid registered to each other and the resulting deviations analyzed, like the difference between corresponding dwell positions (ΔDP) or the discrete Fréchet distance. Further, the dosimetric changes, e.g., coverage index (ΔCI), conformal index (ΔCOIN) and dose non-uniformity ratio (ΔDNR) were considered for a deformed planning target volume (PTV) and the rigid warped PTV structure. The PTV was deformed according to the vector field estimated between the two acquired CTs. RESULTS Over all patients with rigid aligned CTs a mean ΔDP, ΔCI, ΔCOIN and ΔDNR were determined to 2.41 ± 1.73 mm, 3.10 ± 3.17%, 0.009 ± 0.007 and 0.036 ± 0.040, respectively. Considering the deformed PTV ΔCI was estimated to 5.05 ± 4.14%. CONCLUSION In conclusion, in 4% of the cases re-planning would have been beneficial to ensure the planned dose delivery. Large PTV changes or large DP deviations were found to be the main reasons for dosimetric variations.
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Affiliation(s)
- Karoline Kallis
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Marc Ziegler
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Stephan Kreppner
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Vratislav Strnad
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany.
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Tanderup K, Kirisits C, Damato AL. Treatment delivery verification in brachytherapy: Prospects of technology innovation. Brachytherapy 2018; 17:1-6. [PMID: 29406123 DOI: 10.1016/j.brachy.2017.12.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Kari Tanderup
- Department of Oncology, Aarhus University Hospital, Aarhus, Denmark.
| | - Christian Kirisits
- Department of Radiotherapy, Medical University of Vienna, Comprehensive Cancer Center, Vienna, Austria
| | - Antonio L Damato
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY
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