ABSTRACT
In its 2000 report, the Institute of Medicine (IOM) made the public aware of the seriousness of patient safety, reporting that 44,000 to 98,000 individuals die each year in hospitals from medical errors (Institute of Medicine 2000). Radiotherapy (RT), specically, has had its share of signicant events that have caused harm to patients. One of the most publicized series of events was related to the erac-25 radiation machine; six patients received massive overdoses of radiation (Leveson and Turner 1993). ere have been other less publicized, but just as critical, events. Ostrom et al. (1996) examined 35 misadministration events reported to the Nuclear Regulatory Commission (NRC) in 1992 and described seven of them in detail. Four of the seven events were wrong site administrations and the other three events were wrong dose administrations. Direct causes of the events included poor organizational policy and procedures, lack of radiation safety ocer oversight, lack of training and experience, poor supervision, decision errors, poor communication, and hardware failures. Yeung et al. (2005) studied 624 incidents that were reported using an incident reporting system from November 1992 to December 2002. More than 40% of the incidents (263) were due to errors in documentation related to data transfer or inadequate communication. Another 40% of the incidents (252) were due to errors in patient set-up. omadsen et al. (2003) analyzed 134 events of brachytherapy misadministrations. Aer performing a fault tree analysis, they found that 52% of errors were found in four process steps: (1) selection of the sources to place into the applicator; (2) loading of sources into the applicator; (3) using the required units when entering data into the computer; and (4) xing the sources in the applicator or xing the applicator in the patient. More recently, omadsen (2008) reported on two more events related to radiation machines, the Omnitron Event and the Stationary Multileaf Collimator Event.
