Siebert Frank-André, Hirt Markus, Delaperrière Marc, Dunst Jürgen
Clinic of Radiotherapy, University Hospital of Schleswig-Holstein, Campus Kiel, Germany.
Phys Imaging Radiat Oncol. 2022 Sep 17;24:53-58. doi: 10.1016/j.phro.2022.09.006. eCollection 2022 Oct.
Risk management in radiotherapy is of high importance. There is not much data published on errors occurring in the treatment planning process of external beam techniques. The aim of this study was to investigate errors occurring during physics plan review in external beam radiotherapy.
Over a period of 14 months errors observed during the physical review process are reported. The errors were grouped and evaluated regarding treatment machine, technique, and treatment site. In addition, a correlation between frequency of errors and staff shortage was analyzed.
Subgroups of grave errors (g-errors) and slight errors (s-errors) were defined to consider the different impact on the patient and clinical workflow of the errors. In 1056 plans reviewed, 110 errors (41 g-errors, 69 s-errors) were detected. The most common g-errors and s-errors were "Wrong gantry angle at setup field" (n = 19) and "Wrong field label" (n = 24), respectively. A correlation of number of errors and treatment machine, technique, or anatomical site could not be found. No correlation between staff shortage and number of errors was observed.
The process of reviewing treatment plans is a relevant topic to consider in risk analysis of the radiotherapy workflow. The review process could be improved by enhancements in the treatment planning systems, use of digital dose prescription, and treatment planning templates.
放射治疗中的风险管理至关重要。关于外照射技术治疗计划过程中出现的误差，发表的数据不多。本研究的目的是调查外照射放射治疗物理计划审核过程中出现的误差。
报告了在14个月期间物理审核过程中观察到的误差。根据治疗机器、技术和治疗部位对误差进行分组和评估。此外，还分析了误差频率与人员短缺之间的相关性。
定义了严重误差（g误差）和轻微误差（s误差）亚组，以考虑误差对患者和临床工作流程的不同影响。在审核的1056个计划中，检测到110个误差（41个g误差，69个s误差）。最常见的g误差和s误差分别是“设置射野时机架角度错误”（n = 19）和“射野标签错误”（n = 24）。未发现误差数量与治疗机器、技术或解剖部位之间存在相关性。未观察到人员短缺与误差数量之间存在相关性。
治疗计划审核过程是放射治疗工作流程风险分析中需要考虑的一个相关主题。可通过改进治疗计划系统、使用数字剂量处方和治疗计划模板来改善审核过程。
