Risk management in radiation therapy with SEVRRA
DOI:
https://doi.org/10.15392/bjrs.v6i3.549Keywords:
Linear Accelerator, Radiation Therapy, Risk Management, Risk Matrix, SEVRRAAbstract
ABSTRACT
Radiation therapy is a complex treatment modality involving several technological and professional resources as well as a large number of attributions of these professionals with a high degree of interdependence. Thus there are many possibilities of failure in the treatment process that may lead to an accidental exposure. So regulatory agencies have established guidelines in their regulations in order to prevent accidental exposures through security analysis planning and risk management. The System of EValuation of Risk in RAdiotherapy, also known as SEVRRA, is based on the risk matrix methodology and allows the risk assessment of radiation therapy facilities in a prescriptive way, highlighting events leading to high-risk levels and severe consequences for individuals. With SEVRRA it is also possible to establish an importance analysis of the barriers proposed to avoid or mitigate such events.
This work aimed to demonstrate the application of SEVRRA for the risk management of radiation therapy facilities. The risk profile of the facility was determined by identifying the highest risk level events, and the barriers of greater impact for the overall risk level. After implementing some missing barriers in the original facility profile, it was achieved a reduction from 31% to 8% in the number of events leading to high-risk level, showing the effectiveness of SEVRRA for the risk management in radiation therapy facilities.
- Views: 199
- PDF Downloads: 183
Downloads
References
EC – European Commission. General Guidelines on Risk Management in External Beam Radiotherapy. Radiation Protection N° 181, Luxembourg: European Union, 2015. 70p.
IAEA – International Atomic Energy Agency. Application of the Risk Matrix Method to Radiotherapy. IAEA-TECDOC-1685, Vienna: IAEA, 2016. 74p.
COHEN L.; SCHULTHEISS T. E.; KENNAUGH R. C. A radiation overdose incident: Initial data. International Journal of Radiation Oncology, Biology and Physics, v. 33, p. 217–224, 1995.
ASH, D.; BATES, T. Report on the clinical effects of inadvertent radiation underdosage in 1045 patients. Clinical Oncology, v. 6, p. 214-226, 1994.
LEVESON, N.; TURNER, C. S. An investigation of the Therac-25 accidents. IEEEComputer, v. 26, p. 18-41, 1993.
IAEA – International Atomic Energy Agency. The accidental overexposure of radiotherapy patients in Bialystok. PUB-1180, Vienna: IAEA, 2002. 103p.
IAEA – International Atomic Energy Agency. Investigation of an accidental exposure of radiotherapy patients in Panama. PUB-1114, Vienna: IAEA, 2001. 115p.
IAEA – International Atomic Energy Agency. The overexposure of radiotherapy patients in San Jose. PUB-1027, Vienna: IAEA, 1998. 176p.
DERREUMAUX S.; ETARD C.; HUET C.; TROMPIER F.; CLAIRAND I.; BOTTOLLIER-DEPOIS J. F.; AUBERT B.; GOURMELON P. Lessons from recent accidents in radiation therapy in France. Radiation Protection Dosimetry, v.131, p. 130-135, 2008.
IAEA – International Atomic Energy Agency. Programa Nacional de Protección Radiológica en las Exposiciones Médicas. IAEA-TECDOC-1710/S, Vienna: IAEA, 2013. 101p.
IAEA – International Atomic Energy Agency. Análisis Probabilista de Seguridad de Tratamientos de Radioterapia con Acelerador Lineal. IAEA-TECDOC-1670/S, Vienna: IAEA, 2012. 74p.
CNEN – Comissão Nacional de Energia Nuclear. Requisitos de Segurança e Proteção Radiológica para Serviços de Radioterapia. Norma CNEN-NN-6.10, Rio de Janeiro: CNEN, 2014.
ANVISA – Agência Nacional de Vigilância Sanitária. Documento de referência para o Programa Nacional de Segurança do Paciente, Brasília: ANVISA, 2013. 39p.
FORO – Ibero-American Forum of Radiological and Nuclear Regulatory Agencies. Available at: <http://foroiberam.org/>. Last accessed: 05 Mar. 2018.
FORO – Ibero-American Forum of Radiological and Nuclear Regulatory Agencies. SEVRRA. Available at: <http://foroiberam.org/sevrra>. Last accessed: 05 Mar. 2018.
CNSNS – Comisión Nacional de Seguridad Nuclear y Salvaguardias. Sistema de Evaluación del Riesgo en Radioterapia. SEVRRA. Available at: <https://www.gob.mx/cnsns/acciones-y-programas/sistema-de-evaluacion-del-riesgo-en-radioterapia-sevrra >. Last accessed: 05 Mar. 2018.
CSN – Consejo de Seguridad Nuclear. Proyecto MARR (Matrices De Riesgo En Radioterapia). COE-05.01, Madrid: CSN, 2017. 62p.
CNEN – Comissão Nacional de Energia Nuclear. Sistema de Avaliação de Risco em Radioterapia. SEVRRA-BR. Available at: < http://www.cnen.gov.br/2015-07-16-18-05-60 >. Last accessed: 05 Mar. 2018.
VILARAGUT, J.J et al. Prevention of Accidental Exposure in Radiotherapy: The risk matrix approach. Health Physics, v. 104(2), p. 139-150, 2013.
MC DONNELL, D. J.; PAPADOPULOS, S.; PAZ, A. B.; MORONES, R. L.; PEREZ, F. R. Aplicacion de SEVRRA para la Evaluacion de Condiciones de Riesgo en Braquiterapia HDR, In: IRPA Regional Congress, 2013, Rio de Janeiro. Annals. Rio de Janeiro: Sociedade Brasileira de Proteção Radiológica, 2013.
FORO – Ibero-American Forum of Radiological and Nuclear Regulatory Agencies. Extensión de la Aplicación de la Metodología de Matrices de Riesgo Y SEVRRA a Nuevas Técnicas de Radioterapia. Available at: <http://foroiberam.org/web/guest/fondo-documental?documentoId=2339271>. Last accessed: 05 Mar. 2018.
Published
How to Cite
Issue
Section
License
Copyright (c) 2021 Brazilian Journal of Radiation Sciences
This work is licensed under a Creative Commons Attribution 4.0 International License.
Licensing: The BJRS articles are licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons license and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/
