Podmaniczky K C, Mohan R, Kutcher G J, Kestler C, Vikram B
Int J Radiat Oncol Biol Phys. 1985 Aug;11(8):1529-37. doi: 10.1016/0360-3016(85)90342-6.
To improve the quality of patient care by detecting and preventing many types of treatment mistakes, we have implemented a computerized system for recording and verifying external beam radiation treatments on our therapy machines. It inhibits the radiation beam if treatment machine settings do not agree with prescribed values to within maximum permissible deviations (tolerances). The tolerances are determined from experience and adjusted when necessary to make the system more effective and less susceptible to "false alarms." The system uses a common data base for all treatment machines. As a result, it permits statistical analysis and generation of reports based on data encompassing the entire patient population as well as verification of treatments of patients transferred from one machine to another. Reports of verification failures reveal patterns of mistakes. Knowing these, attempts can be made to reduce the frequency of verification failures. "Significant" mistakes that were prevented are extracted by treatment planning personnel from these reports. Analysis of data indicates a rate of approximately 150 "significant" mistakes detected and prevented per machine per year, representing 1.0% of all fields treated. We present and discuss our experiences with the system and with the frequency, patterns, and significance of verification failures. We selected a few of the patients for whose treatments significant set-up mistakes were made, and were detected and prevented by the Record and Verify System. We include discussions of the overall effect these mistakes would have had on dose distribution had they not been prevented.
为了通过检测和预防多种类型的治疗错误来提高患者护理质量，我们已经实施了一个计算机化系统，用于记录和验证我们治疗机器上的外照射放射治疗。如果治疗机器的设置与规定值的偏差不在最大允许偏差（公差）范围内，该系统会抑制辐射束。公差是根据经验确定的，并在必要时进行调整，以使系统更有效且不易产生“误报”。该系统对所有治疗机器使用一个公共数据库。因此，它允许进行统计分析并生成基于涵盖全体患者的数据的报告，以及对从一台机器转移到另一台机器的患者的治疗进行验证。验证失败报告揭示了错误模式。了解这些情况后，就可以尝试降低验证失败的频率。治疗计划人员从这些报告中提取已预防的“重大”错误。数据分析表明，每台机器每年检测并预防的“重大”错误率约为150次，占所有治疗野的1.0%。我们介绍并讨论了我们在该系统方面的经验，以及验证失败的频率、模式和重要性。我们挑选了一些治疗过程中出现重大摆位错误的患者，这些错误已被记录与验证系统检测到并预防。我们还讨论了如果这些错误未被预防，它们对剂量分布可能产生的总体影响。
