1082 / 1359
Errors in radiation oncology: A study in pathways and dosimetric
impact
Eric Klein, Robert E. Drzymala, James A. Purdy and Jeff Michalski
Journal of applied Med. Phys. 2005
Error type:
Typical # of
fraction in which
it was detected
Method of detection
# of
events
#of record and
verify
Incorrect treatment
coordinate(s)
first
Port film
19
7
Wrong gantry angle
first
Port film
15
8
Wrong or omitted
cerrobend block
first
Port film
15
N/A
Incorrect
calculation
2 to 5 fractions
In vivo dosimetry;
physicist chart review
11
N/A
Wrong field size
first
Port film.
9
8
Incorrect collimator
angle
first
Port film
8
3
Missing
compensation filter
2 to 5 fractions
In vivo dosimetry;
physicist chart review
6
N/A
Incorrect MU
2 to 5 fractions
In vivo dosimetry
5
4
Wrong photon
energy
2 to 5 fractions
In vivo dosimetry
3
3
Missing or incorrect
MLC shape
first
Port film
3
Incorrect wedge
direction
1,5,16 fractions
Later diode check;
physics check
3
Incorrect number of
fractions for given
set of fields
1 to 3 fractions
Physicist review
3
2
Incorrect or rotated
compensating filter
2 or 11 fractions
Therapist discovery; in
vivo dosimetry
2
N/A
Patient treated
head to gantry but
scanned foot to
gantry
First fraction
Port film
1
N/A
With entrance in vivo
dose measurements
30/3900
Detected errors
49/3900
Errors over a 30
months on 7 linacs
equiped with R&V
system
.
No complete
electronic transfer of
treatment set-up
data.