Felder Shira, Morley Lyndon, Ng Elizabeth, Chan Kitty, Ballantyne Heather, Di Tomasso Anne, Borg Jette, Bissonnette Jean-Pierre, Breen Stephen, Waldron John, Rink Alexandra, Milosevic Michael
Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada; Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada.
Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada.
Brachytherapy. 2018 Jan-Feb;17(1):16-23. doi: 10.1016/j.brachy.2017.06.010. Epub 2017 Jul 27.
To describe the incidence and type of brachytherapy patient safety events over 10 years in an academic brachytherapy program.
Brachytherapy patient safety events reported between January 2007 and August 2016 were retrieved from the incident reporting system and reclassified using the recently developed National System for Incident Reporting in Radiation Treatment taxonomy. A multi-incident analysis was conducted to identify common themes and key learning points.
During the study period, 3095 patients received 4967 brachytherapy fractions. An additional 179 patients had MR-guided prostate biopsies without treatment as part of an interventional research program. A total of 94 brachytherapy- or biopsy-related safety events (incidents, near misses, or programmatic hazards) were identified, corresponding to a rate of 2.8% of brachytherapy patients, 1.7% of brachytherapy fractions, and 3.4% of patients undergoing MR-guided prostate biopsy. Fifty-one (54%) events were classified as actual incidents, 29 (31%) as near misses, and 14 (15%) as programmatic hazards. Two events were associated with moderate acute medical harm or dosimetric severity, and two were associated with high dosimetric severity. Multi-incident analysis identified five high-risk activities or clinical scenarios as follows: (1) uncommon, low-volume or newly implemented brachytherapy procedures, (2) real-time MR-guided brachytherapy or biopsy procedures, (3) use of in-house devices or software, (4) manual data entry, and (5) patient scheduling and handoffs.
Brachytherapy is a safe treatment and associated with a low rate of patient safety events. Effective incident management is a key element of continuous quality improvement and patient safety in brachytherapy.
描述一个学术性近距离放射治疗项目中10年间近距离放射治疗患者安全事件的发生率及类型。
从事件报告系统中检索2007年1月至2016年8月期间报告的近距离放射治疗患者安全事件，并使用最近开发的国家放射治疗事件报告系统分类法进行重新分类。进行多事件分析以确定常见主题和关键学习要点。
在研究期间，3095例患者接受了4967次近距离放射治疗分次。另外179例患者作为介入研究项目的一部分接受了磁共振引导下的前列腺活检但未进行治疗。共识别出94起与近距离放射治疗或活检相关的安全事件（事件、未遂事件或程序性危害），相当于近距离放射治疗患者的发生率为2.8%，近距离放射治疗分次的发生率为1.7%，接受磁共振引导下前列腺活检患者的发生率为3.4%。51起（54%）事件被分类为实际事件，29起（31%）为未遂事件，14起（15%）为程序性危害。两起事件与中度急性医疗伤害或剂量学严重程度相关，两起与高剂量学严重程度相关。多事件分析确定了五个高风险活动或临床场景如下：（1）不常见、低容量或新实施的近距离放射治疗程序，（2）实时磁共振引导下的近距离放射治疗或活检程序，（3）使用内部设备或软件，（4）手动数据录入，以及（5）患者排班和交接。
近距离放射治疗是一种安全的治疗方法，患者安全事件发生率较低。有效的事件管理是近距离放射治疗持续质量改进和患者安全的关键要素。
