Purpose: To identify hazardous situations in treatments, analyze the nature of errors committed, and assess the value of several analysis techniques.
Materials and methods: The study applied several risk analysis techniques to brachytherapy events (misadministrations) reported to the U.S. Nuclear Regulatory Commission and the International Atomic Energy Agency.
Results: (1) Events usually have multiple causes. (2) Failure to consider human performance in the design of equipment led to a large fraction of the events. (3) Verification procedures often were ineffectual. (4) Many events followed the failure of persons involved to detect that the situation was abnormal, often even though many indications pointed to that fact. Once the event was identified, the response often included actions appropriate for normal conditions, but inappropriate for the conditions of the event. (5) Events tended to happen most with actions having the least time available. (6) Lack of training and procedures covering unusual conditions frequently contributed to events. (7) New procedures or new persons joining a case in the middle present increased hazards.
Conclusions: Risk analysis tools common in industry provide useful information for error reduction in medical settings, although not as effectively, and modification of such techniques could improve their efficacy.