Facilitation of radiotherapeutic error by computerized record and verify systems.
OBJECTIVE
To examine the impact of computerized record and verify (R&V) systems on types of radiotherapeutic error.


METHODS
Radiation therapy treatment errors reported by therapists at the University of Utah between July 1, 1999 and June 30, 2000 were retrospectively reviewed.


RESULTS
During a 1-year period in which 22,542 external beam radiation therapy treatments were administered, 38 treatment errors (representing 0.17% of external beam treatments administered during this period) were identified and reviewed. Nine cases (0.04% of treatments) representing four types of record and verify (R&V)-related errors were identified, in which the department's R&V system played a contributory role in the treatment error.


CONCLUSIONS
The common denominator among these R&V-related errors was excessive reliance upon the computer system by therapists. R&V systems eliminate some, but not all, pathways of radiotherapeutic error. Although R&V systems have assumed a crucial role in the precise and reproducible delivery of increasingly complex radiation therapy treatments, their inability to eradicate all radiotherapeutic errors coupled with their parallel ability to facilitate certain mistakes mandates vigilance on the part of the radiation therapy team. Radiation therapy treatment procedures must preserve careful oversight of R&V functions to minimize prospects for treatment error.
Patton
Gregory A
GA
Northwest Cancer Specialists, PC, Portland, OR 97227, USA. gregory.patton@usoncology.com
Gaffney
David K
DK
Moeller
John H
JH
D000230:Adenocarcinoma / Q000532:radiotherapy / Q000556:secondary; D001943:Breast Neoplasms / Q000532:radiotherapy / Q000601:surgery; D002277:Carcinoma / Q000532:radiotherapy; D004868:Equipment Failure; D005260:Female; D005568:Forms and Records Control; D006801:Humans; D015182:Lymphatic Irradiation; D008207:Lymphatic Metastasis / Q000532:radiotherapy; D008297:Male; D008433:Mathematics; D019300:Medical Errors / Q000145:classification / Q000517:prevention & control / Q000706:statistics & numerical data; D016347:Medical Records Systems, Computerized; D010315:Particle Accelerators; D010355:Patient Identification Systems; D010386:Pelvic Neoplasms / Q000532:radiotherapy / Q000556:secondary; D011471:Prostatic Neoplasms / Q000532:radiotherapy; D011832:Radiation Injuries / Q000209:etiology / Q000517:prevention & control*; D011879:Radiotherapy Dosage; D011881:Radiotherapy, Computer-Assisted; D020266:Radiotherapy, Conformal; D011882:Radiotherapy, High-Energy / Q000295:instrumentation; D012189:Retrospective Studies; D014589:Utah