title: Prevention of accidental exposure in radiotherapy:  the risk matrix approach.
abstract: Knowledge and lessons from past accidental exposures in radiotherapy are very helpful in finding safety provisions to prevent recurrence. Disseminating lessons is necessary but not sufficient. There may be additional latent risks for other accidental exposures, which have not been reported or have not occurred, but are possible and may occur in the future if not identified, analyzed, and prevented by safety provisions. Proactive methods are available for anticipating and quantifying risk from potential event sequences. In this work, proactive methods, successfully used in industry, have been adapted and used in radiotherapy. Risk matrix is a tool that can be used in individual hospitals to classify event sequences in levels of risk. As with any anticipative method, the risk matrix involves a systematic search for potential risks; that is, any situation that can cause an accidental exposure. The method contributes new insights: The application of the risk matrix approach has identified that another group of less catastrophic but still severe single-patient events may have a higher probability, resulting in higher risk. The use of the risk matrix approach for safety assessment in individual hospitals would provide an opportunity for self-evaluation and managing the safety measures that are most suitable to the hospital's own conditions.
authors.affiliation: Centro Nacional de Seguridad Nuclear, Cuba.
authors.forename: J J
authors.initials: JJ
authors.lastname: Vilaragut
authors.forename: C
authors.initials: C
authors.lastname: Duménigo
authors.forename: J M
authors.initials: JM
authors.lastname: Delgado
authors.forename: J
authors.initials: J
authors.lastname: Morales
authors.forename: J D
authors.initials: JD
authors.lastname: McDonnell
authors.forename: R
authors.initials: R
authors.lastname: Ferro
authors.forename: P
authors.initials: P
authors.lastname: Ortiz López
authors.forename: M L
authors.initials: ML
authors.lastname: Ramírez
authors.forename: A
authors.initials: A
authors.lastname: Pérez Mulas
authors.forename: S
authors.initials: S
authors.lastname: Papadopulos
authors.forename: M
authors.initials: M
authors.lastname: Gonçalves
authors.forename: R
authors.initials: R
authors.lastname: López Morones
authors.forename: C
authors.initials: C
authors.lastname: Sánchez Cayuela
authors.forename: A
authors.initials: A
authors.lastname: Cascajo Castresana
authors.forename: F
authors.initials: F
authors.lastname: Somoano
authors.forename: C
authors.initials: C
authors.lastname: Álvarez
authors.forename: A
authors.initials: A
authors.lastname: Guillén
authors.forename: M
authors.initials: M
authors.lastname: Rodríguez
authors.forename: P P
authors.initials: PP
authors.lastname: Pereira
authors.forename: A
authors.initials: A
authors.lastname: Nader
mesh_terms: D004781:Environmental Exposure / Q000517:prevention & control*; D006801:Humans; D016013:Likelihood Functions; D061214:Patient Safety; D011878:Radiotherapy / Q000009:adverse effects*; D018570:Risk Assessment / Q000379:methods*