Enhancing Brachytherapy Safety: Learning from Past Errors and Simulated Training
Description
Brachytherapy demands a high level of precision, and even minor errors can lead to significant consequences and adverse patient outcomes. While reportable medical events are documented in the NRC database and other incident learning systems (e.g. RO-ILS), the information reported is often limited, minimizing the educational value of the incidents. This session aims to address the critical need for error prevention by learning from past brachytherapy errors and developing effective training strategies to mitigate future risks. This session will anonymously share and discuss real-world brachytherapy errors encountered across a variety of clinical settings. Additionally, it will provide an overview of a simulated error training framework designed to allow trainees to identify and analyze mistakes in a safe environment, including those that occur infrequently in clinical practice. Initial results will be presented from a pilot implementation of this simulation-based training model for brachytherapy treatment plan reviews at a single institution. Finally, we will highlight the efforts from the WGMEB to develop publicly available brachytherapy simulated error training cases in ProKnow, building upon the foundation established by the Work Group on Prevention of Errors in Radiation Oncology that created external beam treatment plan review error training resources. While this session will focus on gynecological High Dose Rate brachytherapy, the same methods can be applied to other modalities and body sites. Attendees will gain insight into how analyzing past brachytherapy errors and engaging with simulated error scenarios can enhance clinical training, strengthen chart-checking practices, and ultimately contribute to safer patient care.