RESUMO
Purpose: An incident review of errors related to using high-dose-rate brachytherapy (HDR-BT) and associated patient safety program were presented. This study was based on 9 years' experience using VariSource afterloader system. Material and methods: Analysis was made on radiotherapy (RT) incidents (including near-misses) that were routinely recorded using manual and electronic incident reporting systems between July 2012 and December 2021. Each incident's origin was categorized as 'apparatus', 'system functionality', 'treatment procedure', and 'other causes'. Results: From 8,100 fractions and 2,216 patients, there were 164 RT incidents. The most frequent cases included non-dosimetric errors arising from system malfunction (49/151), difficulties caused by insufficient instruments (47/151), problems with treatment delivery (55/151), and planning procedure errors (13/142). Eleven incidents were near-misses, another 11 were not harmful, and zero were harmful. The frequency rate of dosimetric errors was 0.14 per 100 BT insertions, and 0.5 per 100 patients. The review also discovered 45 of the 164 incidents related to tube sensor failures and source blockages. These delivery errors were associated with 0.56 incidents per 100 insertions and 2.03 incidents per 100 patients, inconveniencing patients in treatment delays. Conclusions: The effectiveness of our HDR-BT safety program was evidenced by low-rate of dosimetric errors. Based on the analysis of 9 years of incidents, the error sources included uncommon or complex procedures, human factors, and work environment (equipment availability and maintenance).
