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Therapy Medical Events in 2013

Summary A patient undergoing external beam radiation therapy was treated for a single dose fraction with treatment fields for a different patient. The patient was being treated for right upper lobe lung carcinoma and hilar adenopathy. The treatment fields for the wrong patient were AP and PA lung fields for the left lung and mediastinum. Both treatment fields were for 200 cGy/fraction. The correct side of the intended patient was treated with the incorrect fields due to correct alignment to the patient's right-sided isocenter. Treatment planning reconstruction with the incorrect fields showed the tumor received about 96% of the anticipated dose coverage planned and the spinal cord receive less dose than originally planned.
Root Cause The patient was not correctly identified.
Corrective Action Therapist will verbalize daily with the patient their name and date of birth before the patient enters the treatment vault. Treatment fields will be moded up after confirmation of the patient's identity.
Effect on Patient Treatment planning reconstruction showed no excessive dose was delivered. The patient received an offcord boost plan of radiation more focused to the tumor volume. No adverse effects are expected due to using the wrong patient's treatment fields.
Summary During simulation the location of the tumor was incorrectly tattooed on the patient. This positioning error was not detected by the physician when the patient setup films were reviewed on the first day of treatment. The patient was incorrectly treated for seven days. On the eighth day new setup films were taken and the setup error was discovered by a radiation therapist and confirmed by the physician.
Root Cause The tumor location was incorrectly located on the patient.
Corrective Action 1. Policies and procedures are being reviewed and updated that pertain to patient simulation and position marks, physician imaging review at the first treatment of a patient, and therapists checks of patient setup at the initial treatment.
2. Assure compliance to the policy that requires filming of patient set up every 5 treatment days.
3. Policies for a "hard stop" before patient treatment begins are being enhanced.
4. A contributing factor was a sudden increase in patient volume and low staffing levels. Methods to rapidly adjust staffing levels to correspond to sudden increases in patient numbers are being developed.
Effect on Patient The patient received less dose to the tumor than intended. This will be compensated for by adding additional treatments with a reduced field size. The patient received a higher dose than intended to the lower right lung and top of liver. While this dose is higher than intended it was still below levels expected to result in noticeable tissue damage. At the time of the report, the patient did not have any noticeable side effects due to the error.

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