WHO: Data errors cause most rad therapy mistakes

Data transfer errors and omissions have been the primary source of radiation therapy patient safety incidents around the world over the past 30 years, according to a report from the World Health Organization (WHO).

WHO's World Alliance for Patient Safety sponsored a review of three decades of documented radiation therapy patient safety incidents, adverse events, near misses, and errors. The findings were published in the July issue of Radiotherapy and Oncology (2009, Vol. 92:1, pp. 15-21).

A research team led by Jesmin Shafiq of the University of New South Wales in Sydney, Australia, reviewed all information published in peer-review journals, conference proceedings, working papers, organizational reports, and local, national, and international databases to identify all reported anomalies during radiation therapy procedures between 1976 and 2007.

They identified a total of 3,125 incidents of patient harm, in which 38 patients died as a result of radiation overdose toxicity or undertreatment. Causes for the incidents were attributed to therapy planning treatment delivery errors, information transfer errors, and lack of knowledge and experience in using radiation therapy equipment and/or computer software.

During the 30-year period, the risk of mild to moderate injurious outcome to patients from radiotherapy errors was approximately 1,500 per 1,000,000 treatment courses, according to Shafiq and colleagues. In the opinion of the research team, rigorously enforced quality assurance programs and frequent peer-review audits of radiotherapy processes continue to be the best deterrents to prevent errors.

There were 4,616 near misses (incidents with no recognizable patient harm) reported in Australia, Canada, Europe, the U.K., and the U.S. -- the only countries providing near-miss statistics -- between 1992 and 2007.

The review was hampered by lack of data from the majority of economically underdeveloped countries, especially those located in Africa and Asia. The researchers also identified a systematic bias in reporting of technology-related incidents rather than mistakes caused by clinical judgment.

As a result of the review findings, the WHO has published a radiotherapy risk profile technical manual, which is available free of charge by clicking here.

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