vol. 5 6/2016 Inżynier i Fizyk Medyczny
320
artykuł
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article
radioterapia
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radiotherapy
for all treatment. The patient is nursed or visited
during a period interval. It is very important to
manage correctly that kind of situations in rela-
tion to appearing next pulse. The members of
staff have been trained to manage the patient
needs and provided treatment to don’t disrupt
the schedule of it. It is very important in terms
a number of pulses as well as interval time kept
between them and finally in relation to a radio-
biological effect of the treatment.
MISSING TREATMENT PULSE
The TDU has an internal system to control
a number of pulses delivered as well as time of
delivery and completing of these pulses. The
unit has two independent data bases where the
treatments are recorded:
––
the user data base (it is also printed off after
completing a whole treatment and kept in
the patient records),
––
engineering logs which are accessible for an
administrator/service user login.
Both of them should confirm all events (eg. all
breaks generated by staff because of the patient
service, any deviations from a standard schedu-
le, any breakdowns and missed treatments) as
well realisation of the treatment.
The issue of those recording systems was de-
tected when the user data base showed the one
missed pulse (27 pulses instead 28 – the pulse no
12 was missed from that record). Unfortunately,
for the Flexitron system the pulse record can
only be reviewed on completion. It means that
verification of the treatment provided could
be verified after completing of it (verification
off-line).
The records didn’t give full information about
the reason which caused missing the pulse. The
user logs showed only lack of 12
th
pulse and time
of that event (Fig. 4). The engineers logs didn’t
contain clear information about technical or not
technical reasons the issue – that record uses
the specific codes and labelling, completely im-
possible to understand by the user or to define
the issues or events appeared (Fig. 5). Also, the
time of the recorded issues/events was diffe-
rent in the user logs and engineering logs. The
issue was reported to the producer of the TDU
and system. The PDR treatment was suspended
till getting the results of the investigation com-
pleted by the manufacturer. That incident never
has found full explanation. Finally the system
Fig. 5
. The engineers log file – the missed pulse detected but not clear which one (different format of recording logs
for the machine and different time than in the user log)
Source: [4].
Fig. 4
. The user logs showing the 12
th
missed pulse
Source: [4].
Fig. 6
. The table – EQD2 calculations for intended treatment and delivered treatment
Source: [4].
