Case studies on the use of the "risk matrix" approach for accident prevention in radiotherapy
Main Article Content
Abstract
External beam radiotherapy is the only practice during which humans are directly exposed to a radiation beam to receive high doses. Accidental exposures have occurred throughout the world, thus showing the need for systematic safety assessments, capable to identify preventive measures and to minimize consequences of accidental exposure. The ‘risk matrix’ approach is a semi quantitative method to evaluate the likelihood and the severity of events by means of a scale, and defines acceptability criteria on the basis of the risk. For each accident sequence identified, the following questions come up: how often is it?, how severe are the consequences? and, what safety measures should be taken to prevent it?. From these answers we can obtain the resulting risk by using the "Risk Matrix" table. In this study we have used this method to conduct the study in 3 cases (real radiotherapy departments). The case study identified the major weaknesses in radiotherapy service and proposed measures to reduce the risk of accidents. The method is practical and it could be applied in hospitals. This approach allows regulators to improve the quality of their inspections and the rigor of the assessments made to grant the operating license to the entities working with radiotherapy
Article Details
How to Cite
Duménigo, C., Vilaragut, J. J., & Morales, J. L. (1). Case studies on the use of the "risk matrix" approach for accident prevention in radiotherapy. Nucleus, (48). Retrieved from http://nucleus.cubaenergia.cu/index.php/nucleus/article/view/538
Section
Ciencias Nucleares
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
Aquellos autores/as que tengan publicaciones con esta revista, aceptan los términos siguientes:
- Los autores/as conservarán sus derechos de autor y garantizarán a la revista el derecho de primera publicación de su obra, el cuál estará simultáneamente sujeto a la Licencia Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) que permite a terceros compartir la obra siempre que se indique su autor y su primera publicación esta revista. Bajo esta licencia el autor será libre de:
- Compartir — copiar y redistribuir el material en cualquier medio o formato
- Adaptar — remezclar, transformar y crear a partir del material
- El licenciador no puede revocar estas libertades mientras cumpla con los términos de la licencia
Bajo las siguientes condiciones:
- Reconocimiento — Debe reconocer adecuadamente la autoría, proporcionar un enlace a la licencia e indicar si se han realizado cambios. Puede hacerlo de cualquier manera razonable, pero no de una manera que sugiera que tiene el apoyo del licenciador o lo recibe por el uso que hace.
- NoComercial — No puede utilizar el material para una finalidad comercial.
- No hay restricciones adicionales — No puede aplicar términos legales o medidas tecnológicas que legalmente restrinjan realizar aquello que la licencia permite.
- Los autores/as podrán adoptar otros acuerdos de licencia no exclusiva de distribución de la versión de la obra publicada (p. ej.: depositarla en un archivo telemático institucional o publicarla en un volumen monográfico) siempre que se indique la publicación inicial en esta revista.
- Se permite y recomienda a los autores/as difundir su obra a través de Internet (p. ej.: en archivos telemáticos institucionales o en su página web) antes y durante el proceso de envío, lo cual puede producir intercambios interesantes y aumentar las citas de la obra publicada. (Véase El efecto del acceso abierto).
La Revista Nucleus solo aceptará contribuciones que no hayan sido previamente publicados y/o procesados, por otra publicación. Cualquier violación ese sentido será considerada una falta grave por parte del autor principal lo cual será objeto valoración por parte del Consejo Editorial, el cual dictaminará al respecto.
References
[1] INTERNATIONAL ATOMIC ENERGY AGENCY. Lessons learned from accidents in radiotherapy. Safety Reports Series No. 17. Vienna: IAEA, 2000.
[2] VILARAGUT JJ, FERRO R, RODRÍGUEZ M, et al. Proceedings del Congreso de la Asociación Internacional de Protección Radiológica (IRPA 12). Buenos Aires, 2008.
[3] INTERNATIONAL ATOMIC ENERGY AGENCY. Investigation of an Accidental Exposure of Radiotherapy Patients in Panamá. Vienna: IAEA, 2001.
[4] INTERNATIONAL ATOMIC ENERGY AGENCY. Investigation of an accidental exposure of radiotherapy patients in Bialystok. Vienna: IAEA, 2004.
[5] US NUCLEAR REGULATORY COMMISION. Good practices for implementing Human Reliability Analysis (HRA). Final Report. NUREG1792. EEUU, 2005.
[6] US DEPARTMENT OF ENERGY. Hazard and Barrier Analysis Guidance Document. EH-33 Office of Operating Experience Analysis and Feedback. Department Of Energy. USA November, 1996.
[7] INTERNATIONAL ATOMIC ENERGY AGENCY. Component Reliability Data for use in Probabilistic Safety Assessment. IAEA TECDOC 478. Vienna: IAEA,1988.
[8] INTERNATIONAL ATOMIC ENERGY AGENCY. International Basic Safety Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources. Safety Series No. 115. Vienna: IAEA, 1996.
[9] ICRP 86. Prevention of Accidental Exposures to patients Undergoing radiation Therapy. Annals of the ICRP. 2000; 30(3).
[10]US NUCLEAR REGULATORY COMMISION. Human Factor Evaluation of Teletherapy. NUREG/ CR-6277. EEUU, 1995.
[11]THOMADSEN B. Towards Probabilistic Risk Assessment in Braquitherapy. Progress Report. IAEA CRP J1.70.05. Viena: IAEA, 2002.
[12]INTERNATIONAL ATOMIC ENERGY AGENCY. Case studies in the application of probabilistic safety assessment techniques to radiation sources. IAEA TECDOC 1404. Vienna: IAEA, 2006.
[2] VILARAGUT JJ, FERRO R, RODRÍGUEZ M, et al. Proceedings del Congreso de la Asociación Internacional de Protección Radiológica (IRPA 12). Buenos Aires, 2008.
[3] INTERNATIONAL ATOMIC ENERGY AGENCY. Investigation of an Accidental Exposure of Radiotherapy Patients in Panamá. Vienna: IAEA, 2001.
[4] INTERNATIONAL ATOMIC ENERGY AGENCY. Investigation of an accidental exposure of radiotherapy patients in Bialystok. Vienna: IAEA, 2004.
[5] US NUCLEAR REGULATORY COMMISION. Good practices for implementing Human Reliability Analysis (HRA). Final Report. NUREG1792. EEUU, 2005.
[6] US DEPARTMENT OF ENERGY. Hazard and Barrier Analysis Guidance Document. EH-33 Office of Operating Experience Analysis and Feedback. Department Of Energy. USA November, 1996.
[7] INTERNATIONAL ATOMIC ENERGY AGENCY. Component Reliability Data for use in Probabilistic Safety Assessment. IAEA TECDOC 478. Vienna: IAEA,1988.
[8] INTERNATIONAL ATOMIC ENERGY AGENCY. International Basic Safety Standards for Protection against Ionizing Radiation and for the Safety of Radiation Sources. Safety Series No. 115. Vienna: IAEA, 1996.
[9] ICRP 86. Prevention of Accidental Exposures to patients Undergoing radiation Therapy. Annals of the ICRP. 2000; 30(3).
[10]US NUCLEAR REGULATORY COMMISION. Human Factor Evaluation of Teletherapy. NUREG/ CR-6277. EEUU, 1995.
[11]THOMADSEN B. Towards Probabilistic Risk Assessment in Braquitherapy. Progress Report. IAEA CRP J1.70.05. Viena: IAEA, 2002.
[12]INTERNATIONAL ATOMIC ENERGY AGENCY. Case studies in the application of probabilistic safety assessment techniques to radiation sources. IAEA TECDOC 1404. Vienna: IAEA, 2006.