PROPOSAL OF PROCEDURES TO PREVENT ERRORS IN RADIOTHERAPY BASED IN LEARNED LESSONS OF ACCIDENTAL EXPOSITIONS / Proposta de procedimentos para evitar erros em radioterapia baseados em lições aprendidas de exposições acidentais

AUTOR(ES)
DATA DE PUBLICAÇÃO

2007

RESUMO

In order to consider some procedures to prevent errors in radiotherapy based in learned lessons of accidental expositions and in accordance with information contained in international reports elaborated by International Atomic Energy Agency (IAEA) and of the data base availability by the European group Radiation Oncology Safety Information System (ROSIS) on the events, a research of the occurred errors was performed. For the evaluation of the incidents a data base based in the ROSIS and added plus a parameter was created "type of error". All the stored data make possible the evaluation of the 839 incidents in terms of frequency of the type of error, the process of detention, the number of reached patients and the degree of severity. Of the 50 types of found errors, the type of error more frequently was “incorrect treatment coordinate ", confirmed with the data of literature and representing 28,96% of the total of the incidents. The results showed 44,44% are discovered at the moment of the treatment and that the process of verification of the fiche or clinical revision of the patient is a verification more occurred insurance and in 43,33% of the searched events. The results indicated that more than 50% of the incidents the severity degree are void and approximately 62% a patient are affected during the accomplishment of the radiotherapy. This work showed that to analyze the data base according to methodology proposal for Klein et al.; for Reason, and Dunscombe et al. is interesting to insert more characteristic detailed in the data base such as: the number of fractions for affected patient, number of fields of treatment for fraction that was affected, shunting line of the prescribed dose and shunting line of the volume prescribed in all the registered in cadastre events. Some causes exist that can lead the errors when patient they are submitted to the radiotherapy. Some measures can be taken so that these errors do not occur as: to carry through dosimetry in vivo "off-axis" with diode to reduce the use of the incorrect direction of the wedge; to use values of the vertical distance with pointer of optic distance (SSD) to prevent error of distance of treatment; to use the system of transference of data DICOM-RT between the stations of work of the planning of treatment and the simulation, being increased the efficiency and accuracy in the treatment; to manually consider the redundancy in the verifications of the calculations carried through for computer or; to use a computerized system of register and verification of the treatment; preventing errors in the which had daily treatments to the incorrect election of the treatment parameters; to implant a magnetic card of identification of the patient with photo, identification number, name of the institution, name of the department, the date of the first emission and responsible doctor to prevent errors of identification and register and could all be used in the process of the treatment. Of this form, these procedures can prevent incident more in radiotherapy and increase the security of the patients.

ASSUNTO(S)

prevenção. prevenção. exposições acidentais radioterapia radioterapia exposições acidentais

ACESSO AO ARTIGO

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