LOOKING MORE DEEPLY AT HUMAN ERROR IN RADIATION THERAPY
FUNDED BY: Nuclear Regulatory Commission
PRIME CONTRACTOR: Brookhaven National Laboratory
PROBLEM: The Nuclear Regulatory commission is charged with monitoring the safe use of nuclear byproducts in hospitals and other medical facilities where they are used for medical treatments such as gamma knife procedures to pinpoint and eradicate brain tumors, and brachytherapy (i.e., inserting radioactive material into the body) for treating certain types of cancers (e.g., bladder, prostate). Unintentional release of nuclear byproducts can lead to serious consequences for patients, hospital staff, and the environment.
APPROACH: Applied Decision Science worked with Brookhaven National Laboratory to understand workflow, common errors, and risks associated with use of nuclear byproducts in medical facilities. Using a combination of observations, interviews, and review of the Nuclear Material Events Database, we identified human performance issues associated with gamma knife and brachytherapy.
IMPACT: Our analysis unpacked the commonly used catch all category “human error” to identify underlying systemic and design issues that led to errors. Analysis of event reports over time and across procedures revealed human performance issues tied to particular steps in specific medical procedures. These findings served as the basis for a Nuclear Regulatory report (NUREG-2170) titled, “A Risk-Informed Approach to Understanding Human Error in Radiation Therapy,” and led to revisions of a Job Aid designed to help NRC inspectors learn about potential human performance issues so they can be better informed when completing inspections of medical facilities. The Job Aid includes one-page descriptions summarizing human performance issues, and drawing examples from error discussions and event narratives.
Militello, L.G., Brown, W.S., Wreathall, J., Cooper, S.E., Marble, J., Lopez, C., (2011). Supporting NRC Inspections of Byproduct Use in Medical Facilities. Proceedings of the 55th Human Factors and Ergonomics Society Annual Meeting, pp. 788-792, Santa Monica: HFES.
Lopez, C., Militello, L.G., Brown, W.S., Wreathall, J., Marble, J., Cooper, S. E. (2012). Using incident reports to identify vulnerabilities: A case study in radiation therapy. Proceedings of the 56th Human Factors and Ergonomics Society Annual Meeting, Boston: HFES.
Wreathall, J., Brown, W. S., Militello, L., Cooper, S. E., Lopez, C., & Franklin, C. (2017). A risk-informed approach to understanding human error in radiation therapy (NUREG-2170). Office of Nuclear Regulatory Research. Washington, D.C.: U.S. Nuclear Regulatory Commission.