Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: “garbage in, garbage out”
Due to the large number of steps and the number of persons involved in the preparation of a radiation treatment, the transfer of information from one step to the next is a very critical point. Errors due to inadequate transfer of information will be reflected in every next step and can seriously aff...
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| Veröffentlicht in: | Radiotherapy and oncology 1992-04, Vol.23 (4), p.217-222 |
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| container_title | Radiotherapy and oncology |
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| creator | Leunens, G. Verstraete, J. Van den Bogaert, W. Van Dam, J. Dutreix, A. van der Schueren, E. |
| description | Due to the large number of steps and the number of persons involved in the preparation of a radiation treatment, the transfer of information from one step to the next is a very critical point. Errors due to inadequate transfer of information will be reflected in every next step and can seriously affect the final result of the treatment. We studied the frequency and the sources of the transfer errors. A total number of 464 new treatments has been checked over a period of 9 months (January to October 1990). Erroneous data transfer has been detected in 139/24 128 ( |
| doi_str_mv | 10.1016/S0167-8140(92)80124-2 |
| format | Article |
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major deviations, only occurring in 0.1% of the transferred parameters, affected 5% (25/464) of the new treatments. The sources of these large deviations were nearly always human mistakes, whereas a considerable number of the smaller deviations were, in fact, consciously taken decisions to deviate from the intended treatment. Nearly half of the major deviations were introduced during input of the data in the check-and-confirm system, demonstrating that a system aimed to prevent accidental errors, can lead to a considerable number of systematic errors if used as an uncontrolled set-up system. The results of this study show that human mistakes can seriously affect the outcome of patient treatments. Therefore, patient-related quality assurance procedures are highly recommended at the first treatment sessions to eliminate, at least, the systematic errors.</description><identifier>ISSN: 0167-8140</identifier><identifier>EISSN: 1879-0887</identifier><identifier>DOI: 10.1016/S0167-8140(92)80124-2</identifier><identifier>PMID: 1609125</identifier><language>eng</language><publisher>Ireland: Elsevier Ireland Ltd</publisher><subject>Check-and-confirm systems ; Data transfer ; Humans ; In vivo dosimetry ; Portal imaging ; Quality assurance ; Quality Control ; Radiotherapy Dosage - standards ; Radiotherapy, Computer-Assisted - standards</subject><ispartof>Radiotherapy and oncology, 1992-04, Vol.23 (4), p.217-222</ispartof><rights>1992 Elsevier Science Publishers B.V. All rights reserved</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c360t-ead29c002b3aa3b74b952be67e9d1ef68b16142c5979a8f68c0b956df8e7f9b83</citedby><cites>FETCH-LOGICAL-c360t-ead29c002b3aa3b74b952be67e9d1ef68b16142c5979a8f68c0b956df8e7f9b83</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><linktohtml>$$Uhttps://dx.doi.org/10.1016/S0167-8140(92)80124-2$$EHTML$$P50$$Gelsevier$$H</linktohtml><link.rule.ids>314,780,784,3548,27923,27924,45994</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/1609125$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Leunens, G.</creatorcontrib><creatorcontrib>Verstraete, J.</creatorcontrib><creatorcontrib>Van den Bogaert, W.</creatorcontrib><creatorcontrib>Van Dam, J.</creatorcontrib><creatorcontrib>Dutreix, A.</creatorcontrib><creatorcontrib>van der Schueren, E.</creatorcontrib><title>Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: “garbage in, garbage out”</title><title>Radiotherapy and oncology</title><addtitle>Radiother Oncol</addtitle><description>Due to the large number of steps and the number of persons involved in the preparation of a radiation treatment, the transfer of information from one step to the next is a very critical point. Errors due to inadequate transfer of information will be reflected in every next step and can seriously affect the final result of the treatment. We studied the frequency and the sources of the transfer errors. A total number of 464 new treatments has been checked over a period of 9 months (January to October 1990). Erroneous data transfer has been detected in 139/24 128 (<1%) of the transferred parameters; they affected 26% (119/464) of the checked treatments. Twenty-five of these deviations could have led to large geographical miss or important over- or underdosage (much more than 5%) of the organs in the irradiated volume, thus increasing the complications or decreasing the tumour control probability, if not corrected. Such
major deviations, only occurring in 0.1% of the transferred parameters, affected 5% (25/464) of the new treatments. The sources of these large deviations were nearly always human mistakes, whereas a considerable number of the smaller deviations were, in fact, consciously taken decisions to deviate from the intended treatment. Nearly half of the major deviations were introduced during input of the data in the check-and-confirm system, demonstrating that a system aimed to prevent accidental errors, can lead to a considerable number of systematic errors if used as an uncontrolled set-up system. The results of this study show that human mistakes can seriously affect the outcome of patient treatments. Therefore, patient-related quality assurance procedures are highly recommended at the first treatment sessions to eliminate, at least, the systematic errors.</description><subject>Check-and-confirm systems</subject><subject>Data transfer</subject><subject>Humans</subject><subject>In vivo dosimetry</subject><subject>Portal imaging</subject><subject>Quality assurance</subject><subject>Quality Control</subject><subject>Radiotherapy Dosage - standards</subject><subject>Radiotherapy, Computer-Assisted - standards</subject><issn>0167-8140</issn><issn>1879-0887</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>1992</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNqFUc1qFjEUDaLUz-ojFLISC45NMr9xI1JsKxS6UNfhzuTmMzKT-bzJFLrrM3StL9cnMe20unSTH84593DPYexAindSyOboSz7aopOVeKPVYSekqgr1hG1k1-pCdF37lG3-Up6zFzH-EEIoUbZ7bE82QktVb9jN2TJB4Eg0U-Q-cAsJeCII0SFxu5APW56-I98R7oAg-TlwCJZbHP0l0hWfHSewfkUSIaQJQ-LgHA7pUe18gJETxmVM7_nt9a8tUA9bzJZv-eN7XtLt9e-X7JmDMeKrh3uffTv59PX4rDi_OP18_PG8GMpGpALBKj3kjfoSoOzbqte16rFpUVuJrul62chKDbVuNXT5P4jMaKzrsHW678p99nqdu6P554IxmcnHAccRAs5LNG0pRFnVOhPrlTjQHCOhMzvyE9CVkcLcdWHuuzB3QRutzH0XRmXdwYPB0k9o_6nW8DP-YcUxb3npkUwcPIYBraccnbGz_4_DH7dena8</recordid><startdate>19920401</startdate><enddate>19920401</enddate><creator>Leunens, G.</creator><creator>Verstraete, J.</creator><creator>Van den Bogaert, W.</creator><creator>Van Dam, J.</creator><creator>Dutreix, A.</creator><creator>van der Schueren, E.</creator><general>Elsevier Ireland Ltd</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>19920401</creationdate><title>Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: “garbage in, garbage out”</title><author>Leunens, G. ; Verstraete, J. ; Van den Bogaert, W. ; Van Dam, J. ; Dutreix, A. ; van der Schueren, E.</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c360t-ead29c002b3aa3b74b952be67e9d1ef68b16142c5979a8f68c0b956df8e7f9b83</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>1992</creationdate><topic>Check-and-confirm systems</topic><topic>Data transfer</topic><topic>Humans</topic><topic>In vivo dosimetry</topic><topic>Portal imaging</topic><topic>Quality assurance</topic><topic>Quality Control</topic><topic>Radiotherapy Dosage - standards</topic><topic>Radiotherapy, Computer-Assisted - standards</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Leunens, G.</creatorcontrib><creatorcontrib>Verstraete, J.</creatorcontrib><creatorcontrib>Van den Bogaert, W.</creatorcontrib><creatorcontrib>Van Dam, J.</creatorcontrib><creatorcontrib>Dutreix, A.</creatorcontrib><creatorcontrib>van der Schueren, E.</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Radiotherapy and oncology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Leunens, G.</au><au>Verstraete, J.</au><au>Van den Bogaert, W.</au><au>Van Dam, J.</au><au>Dutreix, A.</au><au>van der Schueren, E.</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: “garbage in, garbage out”</atitle><jtitle>Radiotherapy and oncology</jtitle><addtitle>Radiother Oncol</addtitle><date>1992-04-01</date><risdate>1992</risdate><volume>23</volume><issue>4</issue><spage>217</spage><epage>222</epage><pages>217-222</pages><issn>0167-8140</issn><eissn>1879-0887</eissn><abstract>Due to the large number of steps and the number of persons involved in the preparation of a radiation treatment, the transfer of information from one step to the next is a very critical point. 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| ispartof | Radiotherapy and oncology, 1992-04, Vol.23 (4), p.217-222 |
| issn | 0167-8140 1879-0887 |
| language | eng |
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| source | MEDLINE; ScienceDirect Journals (5 years ago - present) |
| subjects | Check-and-confirm systems Data transfer Humans In vivo dosimetry Portal imaging Quality assurance Quality Control Radiotherapy Dosage - standards Radiotherapy, Computer-Assisted - standards |
| title | Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: “garbage in, garbage out” |
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