July, 2018
A Message From the President
Welcome to the July 2018 edition of the American Brachytherapy Society’s BrachyBlast newsletter.

We have hit the ground running in the past month to prepare for the year ahead. Committee Chairs and Co-Chairs have begun to assemble and meet with their committees to set goals and solidify action plans to ensure we meet our 2018-2019 goals. We are always looking for individuals to participate in the society and to attract new brachytherapy enthusiasts to the membership. If someone you know would like to join the organization or you would like to volunteer to serve the society in the upcoming year, please contact us and let us know your interests.

This month we are featuring an article from Chirag Shah, Social Media Committee Chair, about the social media achievements during this year’s Annual Meeting and how we will leverage these platforms in the year to come.

The 2019 Annual Meeting Scientific Planning committee led by Chairs Brett Cox and Kristin Bradley is off to a great start. We will have more details to share with you in the Summer Newsletter, but until then, mark your calendars!

2019 ABS Annual Meeting
June 13-15
Miami, Florida

Thank you,
Peter F. Orio III, DO, MS
Follow Us on Twitter:   
ABS Annual Meeting:
Social Media Front and Center
Chirag Shah, MD
ABS Social Media Committee Chair
Cleveland Clinic
As part of the Annual Meeting this year, the American Brachytherapy Society Social Media Committee has worked to highlight the amazing program put together by the Meeting Committee. This effort began before the meeting with promotional activity as well as highlight key sessions (ex. Socioeconomic sessions) on Twitter. Once the meeting began, sessions and speakers were the focus, with member of the committee and other meeting attendees tweeting out sessions, pictures, and key takeaways from the meeting; also key society events and awards were focused on including the Henschke award and the awarding of the Fellows of the American Brachytherapy Society. Poster walkthroughs were also highlighted, celebrating the great work done by our attendees. Throughout the meeting, the use of the hashtag #ABSBRACHY18 allowed for individuals to capture tweets from an array of posters as well as the society’s Twitter handle. Finally, the first ever Social Media Session was held at the meeting with keynote speaker Dr. Drew Moghanaki and panelists (Dr. Brett Cox and myself) discussing how to get on to social media as well as discussing the value of social media as part of a radiation oncology and brachytherapy practice. While the presentations got the session off to great start, it was the participants in the audience who drove an extremely productive session that focused on how to drive value out of social media and how do so in a safe and meaningful way. We look forward to continuing this session and building upon it in the years to come. Additionally, at next year’s annual meeting we will increase our focus on sessions as well as presenters and add more interactive components to the program. Thanks for making this year’s meeting a great success and see you in Miami !
Patient Safety Corner
Sarah Price, Graduate Student
Panagiota Galanakou, Graduate Student
Florida Atlantic University
Medical Event Case 0001

Patient safety is a critical goal for all of those involved in delivering brachytherapy treatment. Safety reporting followed by analysis of any errors in treatment delivery are essential steps in optimizing patient safety. The series of Brachyblast submissions will focus on sharing brachytherapy events with the ABS membership to prevent any future events. We are two graduate Medical Physics students at a CAMPEP accredited institution who share an interest in both brachytherapy and patient safety. We are directly overseen by Zoubir Ouhib who, along with the ABS Patient Safety Committee, has graciously allowed us to pursue this task.

Over the next few months, you will be presented with a series of medical events in brachytherapy that have occurred around the world. Please be aware that the details on the reporting information might not be as complete as we hope to have. Your objective will be to suggest corrective action for each event. We also welcome any preventive actions that you might have in place to prevent such events from occuring. The responses received will then be prioritized and disseminated with the goal of sharing a focus on patient safety culture. Without further ado, here is your first case:

Wrong Source Transfer Tube Length

Introductory Information: Reported to SAFRON on October 31, 2016, this major incident affected 68 patients treated with the Varian Varisource iX HDR afterloader & planned with BrachyVision V13.5. The event was discovered post treatment completion by the radiation oncologist during a clinical review of the patient. The range of dose deviation was 20-50% of the prescribed dose. Two related errors that occurred will be discussed.

This afterloader model accommodates variable length catheters, and as a pre-treatment check, performs a channel too short test, but not a channel too long test. The vendor also provides source transfer tubes of various lengths, through which the source is transferred between the afterloader and applicators. The transfer tubes attach to the applicators or needles using a “click-fit” connector, and to the afterloader using a “Quick-Connect” mechanism.

Error 1 (11 patients): The Varisource iX HDR system was commissioned with a click-fit set of predefined length named "Click-fit Set A". A few months following commissioning, a new Miami applicator was procured with a new "Click-fit set B" that is 10cm longer than "Click-fit set A". In July 2016, the central channel of "Click-Fit set A" broke and the planning team decided to use the transfer tube from "Click-Fit Set B" until it can be replaced. Hence the planning team planned treatments using "Click Fit Set B" for the central channel and used "Click fit Set A" for the two ovoids. The above was communicated to the radiotherapists responsible for connecting the Click-fit tubes and administering the treatment of the patients. Unfortunately, some radiotherapists misunderstood the change and thought all 3 connections must now use "Click-Fit Set B". This resulted in 11 patients being treated on the ovoids 10 cm lower than they should have been treated. An in-depth investigation was done on all brachytherapy patients treated from June 2016. All affected patient plans were re-planned to include the error showing the differences in doses from what was prescribed and what was administered. This error unfortunately resulted in major differences in planned vs. delivered dose.

Error 2 (57 patients): During investigation of Error 1 it was decided to remeasure and confirm lengths of all the brachytherapy transfer tubes and applicators used at this facility. During this verification it was found that the length of the Tandem (channel 1) for the Miami applicator was incorrectly entered in the TPS (Treatment Planning System). When using "Click-fit set B" the length of the transfer tube with the tandem of the Miami applicator measured 133.5 cm. The vendor confirmed the measurement of 133.5 cm. Therefore, the planning applicator length should be 132 cm (the extra 1.5 cm accounts for the Quick Connect part of the machine). The planning team was using 130 cm planning length instead of 132 cm. The 130 cm that had been used to plan the patient plans was a default applicator length and was also used in the BrachyVision demo plans. This hadn’t been manually measured or tested at this facility after the new applicator was procured. This resulted in all patients in error 1 being treated a further 2 cm lower that prescribed and an additional 57 patients also treated 2 cm lower that what was required. All affected patient plans were re-planned to include the error showing the differences in doses from what was prescribed and what was administered.

When you are considering corrective actions try answering the following:

1.        What safety barrier failed to identify the incident?
2.        What possible safety barrier identified the incident?
3.        What safety barrier might have identified the incident?
4.        What possible factors contributed to the incident?

These questions can lead you to address the key question: What preventive action(s) could stop reoccurrence of a similar event?

Please send corrective action suggestions before August 6, 2018 to: PreventMedEvent@gmail.com including the title of the event (or case #), your name, your institution (Optional), and your profession (Med. Phys., Rad. Onc., etc.).

We are eager to receive your reply on how you would have dealt with the situation if it had occurred in your institution and what you have in place that would have prevented similar events. Please look for our follow up report in next month’s Brachyblast where we will present the committee’s selected responses. The next medical event case (0002) will be presented in the following Brachyblast newsletter. Thank you in advance for your feedback that will make a difference.

“Noticing that something is broken is an essential prerequisite for coming up with a creative solution to fix”
The ABS Wants You!
Want to get more involved with the ABS? Here's your chance! Our goal to reshape the vision and future of the ABS to best serve the industry continues to guide how we approach every aspect of the organization. We've revamped our volunteer opportunities to better meet your needs. If you're interested in being part of one our committees, please feel free to fill out an interest form and return to Melissa Pomerene .
We look forward to working with you!
of Directors 
  2018-2019 ABS Board of Directors

Peter F. Orio, III, DO, MS , President
Daniel G. Petereit, MD, President Elect
Firas Mourtada, PhD, Vice President
Ann Klopp, MD, PhD, Treasurer
Zoubir Ouhib, MS, Secretary
Catheryn Yashar, MD, Chairwoman of the Board
Steven J. Frank, MD, Past Chairman of the Board

Sushil Beriwal, MD
Christopher L. Deufel, PhD
Peter J. Rossi, MD
Timothy Showalter, MD