A 2-year review of recent Nuclear Regulatory Commission events: What errors occur in the modern brachytherapy era?

Abstract

To perform a retrospective analysis of recently reported brachytherapy errors to the Nuclear Regulatory Commission and to compare with historical trends. All events reported in the 2-year period from January 1, 2009 to December 31, 2010 were categorized and analyzed. The 4 main areas of dose delivery were Gamma Knife radiosurgery, therapeutic radiopharmaceutical administration, high-dose-rate brachytherapy, and low-dose-rate brachytherapy. The different types of errors were wrong site, wrong dose, unintended exposure, lost or leaking source, or other. The causes of events were specified as the following: communication errors, equipment malfunction, human error, lack of training, or miscellaneous. One hundred and forty-seven events were found in the 2-year period. This error reporting rate far surpasses previous reports. The greatest number of events reported was for low-dose-rate brachytherapy, and the most common cause of error was human error. Wrong dose was the error that occurred most often, followed by wrong site. Very simple treatment errors, such as wrong patient, or wrong side of patient treated, are still occurring. Newer, complex deliveries such as high-dose-rate partial breast irradiation and low-dose-rate prostate brachytherapy also had a large number of events reported in this sampling. This report can help institutions establish needs for quality assessment and quality control processes.