What, exactly, is intended by “any delivery of radiotherapy to the wrong region”? Are even minor variations in the field considered sentinel events?
The intent here is the same as requiring a root cause analysis for a wrong site surgery. The fact of a wrong site delivery of radiotherapy carries implications of system problems that should be understood and, as appropriate, redesigned. With regard to “minor variations,” it is recognized that as with any process, there will be some degree of common cause variation, which is within the range of acceptability for that procedure. Any variation from the intended field of treatment that is within the range considered by the medical physics community as acceptable would not be considered by the Joint Commission to be a reviewable sentinel event. A variation greater than that, i.e., a special cause variation, should be managed as a sentinel event. Additional detail on this topic is available from the NRC for radiopharmaceuticals and the FDA for radiation-generating equipment.
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