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An Audit for Radiotherapy Errors and Identification of Associated Casual Factors in a Low Income Radiotherapy Setting

E Belay1*, (1) Addis Ababa University, Addis Ababa,


(Sunday, 7/14/2019) 5:00 PM - 6:00 PM

Room: 301

Purpose: The study aimed to measure the occurrence of radiotherapy errors and identify associated casual factors (latent failures) in a resource constrained radiotherapy setting.

Methods: Treatment records of patients those have been treated in the last 10 years (2009 to 2018) with external beam radiotherapy in the department were randomly selected and audited for radiotherapy errors. For each identified error, patient treatment details, treatment step where error initiated, individuals of involved staff, and event descriptions were recorded in the Excel sheet. Then, Human Factor Analysis and Classification System (HFACS) was used to analysis type of unsafe acts (active errors) and associated casual factors (latent failures.

Results: A total of 2500 treatment records were audited within 9 months and 342 human errors were detected (rate of 13.6%). Of these, 140, 130 and 72 errors were initiated at planning directive, treatment planning and delivery steps respectively. Of 342 human errors, 179 (55%) and 163 (45%) errors were skill-based and decision type of unsafe acts, respectively and the difference is not statistically significant at p= 0.05. No violation type of unsafe acts found in the study. According to HFACS, 1799 casual factors (latent failures) were determined and “Organizational influence� and “unsafe supervision� casual category levels contributed more and associated with all identified errors. Three Radiation Oncologists (RO1, RO2 and RO3) and a Medical Physicist (MP1) strongly (p<0.001 and phi correlations > 0.3) associated with specific error, i.e., “RO1 and incomplete prescription�, “RO2 and swapping field parameters�, “RO3 and incorrect field labeling�, and “MP1 and incorrect data entry to TPS�.

Conclusion: All errors were related to human behavior of unsafe acts. Organizational influence and unsafe supervision attributed to all identified errors that indicated the occurrence of errors was not random in the department. Therefore, quality and safety reforms should be taken at organizational level.

Funding Support, Disclosures, and Conflict of Interest: This reserarch study was supported by the IAEA through a national Technical Cooperation Project. Ther is no any conflict of interest.


Not Applicable / None Entered.


TH- External beam- photons: General (most aspects)

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