IAEA培训材料-近年放射性事故分析.pptVIP

Prevention of accidental exposure in radiotherapy Module title Part No...., Module No....Lesson No IAEA Prevention of accidental exposure in radiotherapy Module 2.10: Accident update – some newer events (UK, USA, France) 1st example: Incorrect manual parameter transfer (UK) Background January 2006 at the Beatson Oncology Centre (BOC) in Glasgow, Scotland At the time: Radiotherapy physics staffing levels in Scotland less than 60% of the recommended level “Glasgow has problems with recruiting physicists, as shown by their high number of vacancies.” What happened? 5th January 2006, Lisa Norris, 15 years old, started her whole CNS treatment at BOC The treatment plan was divided into head-fields and lower and upper spine-fields This is considered to be a complex treatment plan, performed about six times per year at the BOC. Discovery of accident “Planner X” calculated another plan of the same kind and made the same mistake This time, the error was discovered by a senior checker (1st of Feb ‘’06) The same day, the error in calculations for Lisa Norris was also identified Lessons to learn Ensure that all staff Are properly trained in safety critical procedures Are included in training programmes and has supervision as necessary, and that records of training are kept up-to-date Understand their responsibilities Include in the Quality Assurance Program Formal procedures for verifying the risks following the introduction of new technologies and procedures Independent MU checking of ALL treatment plans Review staffing levels and competencies References Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006. Report of an investigation by the Inspector appointed by the Scottish Ministers for The Ionising Radiation (Medical Exposures) Regulations 2000 (2006) Cancer in Scotland: Radiotherapy Activity Planning for Scotland 2011 – 2015. Report of The Radiotherapy Activity Planning Steering Group’ The