| Sumario: | Background: Radiation therapy is a common lifesaving practice in the treatment of cancer, yet there is the potential for error that may cause patient harm or death. Methods: Using a retrospective mixed-methods design, we studied a two-year period of event reports submitted by hospitals to the Pennsylvania Patient Safety Reporting System (PA-PSRS) database and targeted those reports that described errors in radiation therapy. We analyzed the relation between the following primary variables: event type, whether it reached the patient, phase of radiation therapy when the risk factor originated, and risk factor (i.e., event impetus). Results: Our sample included 245 event reports from 40 hospitals. Among the 245 reports, 60% of the errors reached the patient, 71% of the sample were a wrong dose, and 29% described a delay in treatment. Across all six phases of radiation therapy, 38% of events originated from the treatment planning phase and 40% were from the treatment delivery phase. We identified 23 unique categories of risk factors that acted as the impetus. The most frequently identified were malfunction of hardware/software, wrong contour, absent or wrong accessory, wrong position, and wrong or low-quality images. Conclusions: The present study expanded upon many of the prior radiation therapy studies by exploring the relation among the various combinations of the primary variables. The study highlights the current risks in the practice of radiation therapy and the broad range of conditions in which errors may occur. Online Supplement Appendix S1 provides a list of mitigation strategies aimed at detecting and preventing the risk factors identified in the present study.
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