Human Factors in Radiation Therapy

Misadministrations during remote afterloading brachytherapy treatment sessions were reported to the Nuclear Regulatory Commission (NRC). Human factors issues were implicated in many of the incidents.

NRC contracted with PSE to identify the root causes of misadministrations and to recommend improvements in remote afterloading brachytherapy equipment, procedures, and practices.

The Approach

Radiation therapy patient

PSE conducted detailed field assessments at 23 hospitals and clinics nationwide of the overall process from patient intake to treatment follow-up.

Assessment methods included naturalistic observations; videotaping treatment sessions; staff interviews; review of training and treatment records; and evaluation of facility organizational factors.

The Solution

Radiation equipment

Human factors function, task, and error analyses uncovered critical, error-prone aspects of remote afterloading brachytherapy, including equipment design, work processes, ergonomics, training, and organizational and administrative issues.

Benefits

Recommendations for process improvement and error reduction were published, including employee indoctrination and training, system redesign, organizational support and oversight, improved operator backup, and various checks and balances.

Additional Information

Callan, J.R., Kelly, R.T., Quinn, M.L., Gwynne, J.W., Moore , R.A., et al. (May 1995). Human factors evaluation of remote afterloading brachytherapy: Human error and critical tasks in remote afterloading brachytherapy and approaches for improved system performance , NUREG/CR-6125, Vol. 1, U.S. Nuclear Regulatory Commission, Washington , DC.

Callan, J.R., Gwynne, J.W., Kelly, R.T., Muckler, F.A., Saunders, W.M., Lepage, R.P., Chin, E., Schoenfeld, I., and Serig, D.I. (June, 1995). Human Factors Evaluation of Remote Afterloading Brachytherapy: Function and Task Analysis , NUREG/CR-6125, Vol. 2, US Nuclear Regulatory Commission, Washington , DC.

Callan, J.R., Kelly, R.T., Quinn, M.L., Moore , R.A., et al. (June 1995). Supporting Analyses of Human-System Interfaces, Procedures, Practices, Training, Organizational Practices and Policies , NUREG/CR-6125, Vol. 3 , US Nuclear Regulatory Commission, Washington , DC.