临床放射治疗实践中监测单位计算的人为误差。

Human errors in the calculation of monitor units in clinical radiotherapy practice.

作者信息

Calandrino R, Cattaneo G M, Del Vecchio A, Fiorino C, Longobardi B, Signorotto P

机构信息

Servizio di Fisica Sanitaria, Istituto Scientifico H San Raffaele, Milan, Italy.

出版信息

Radiother Oncol. 1993 Jul;28(1):86-8. doi: 10.1016/0167-8140(93)90193-c.

DOI:10.1016/0167-8140(93)90193-c

PMID:8234876

Abstract

Human mistakes are an important source of error in all steps of radiotherapy planning and their incidence should be investigated. As has been recognized by different authors and by the ICRU [4], the human error rate in the calculation of monitor units (MU) is relatively high. At our institute, we measured the human error rate in the calculation of MU by an independent check of the calculation. From September 1991 to June 1992 we identified and corrected 17 serious errors (deviation from the prescribed dose > or = 5%) over 890 controls (1.9%) (daily dose errors). We also found a serious global dose error rate (i.e. the errors induced on the total reference dose for the complete course of the treatment) of 1.3% (9/685) during the period November 1991-June 1992. These values suggest the importance of human errors in the calculation of MU and also confirm the validity of the independent check of MU calculation as one of the simplest ways of avoiding erroneous dose delivery by incorrect calculation of MU.

摘要

人为失误是放射治疗计划所有步骤中错误的一个重要来源，其发生率应予以调查。正如不同作者和国际辐射单位与测量委员会（ICRU）所认识到的那样[4]，监测单位（MU）计算中的人为错误率相对较高。在我们研究所，我们通过对计算进行独立检查来测量MU计算中的人为错误率。从1991年9月到1992年6月，在890次检查中（1.9%）（每日剂量误差），我们识别并纠正了17起严重错误（与规定剂量的偏差≥5%）。在1991年11月至1992年6月期间，我们还发现严重的总体剂量误差率（即整个治疗过程中对总参考剂量产生的误差）为1.3%（9/685）。这些数值表明了人为错误在MU计算中的重要性，也证实了对MU计算进行独立检查作为避免因MU计算错误而导致错误剂量输送的最简单方法之一的有效性。