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Search indexed NASA NTRS and DOE OSTI research on propulsion, heat transfer, battery materials and energy systems. Follow report and document links to the original sources.

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All sourcesNASA NTRSDOE OSTI
NASA NTRS2007

Global Distortion of GPS Networks Associated with Satellite Antenna Model Errors

Recent studies of the GPS satellite phase center offsets (PCOs) suggest that these have been in error by approx.1 m. Previous studies had shown that PCO errors are absorbed mainly by parameters representing satellite clock and the radial components of site position. On the basis of the assumption that the radial errors are equal, PCO errors will therefore introduce an error in network scale. However, PCO errors also introduce distortions, or apparent deformations, within the network, primarily in the radial (vertical) component of site position that cannot be corrected via a Helmert transformation. Using numerical simulations to quantify the effects of PC0 errors, we found that these PCO errors lead to a vertical network distortion of 6-12 mm per meter of PCO error. The network distortion depends on the minimum elevation angle used in the analysis of the GPS phase observables, becoming larger as the minimum elevation angle increases. The steady evolution of the GPS constellation as new satellites are launched, age, and are decommissioned, leads to the effects of PCO errors varying with time that introduce an apparent global-scale rate change. We demonstrate here that current estimates for PCO errors result in a geographically variable error in the vertical rate at the 1-2 mm/yr level, which will impact high-precision crustal deformation studies.

Cardellach, E.↗
NASA NTRS2014

Combined Uncertainty and A-Posteriori Error Bound Estimates for General CFD Calculations: Theory and Software Implementation

This workshop presentation discusses the design and implementation of numerical methods for the quantification of statistical uncertainty, including a-posteriori error bounds, for output quantities computed using CFD methods. Hydrodynamic realizations often contain numerical error arising from finite-dimensional approximation (e.g. numerical methods using grids, basis functions, particles) and statistical uncertainty arising from incomplete information and/or statistical characterization of model parameters and random fields. The first task at hand is to derive formal error bounds for statistics given realizations containing finite-dimensional numerical error [1]. The error in computed output statistics contains contributions from both realization error and the error resulting from the calculation of statistics integrals using a numerical method. A second task is to devise computable a-posteriori error bounds by numerically approximating all terms arising in the error bound estimates. For the same reason that CFD calculations including error bounds but omitting uncertainty modeling are only of limited value, CFD calculations including uncertainty modeling but omitting error bounds are only of limited value. To gain maximum value from CFD calculations, a general software package for uncertainty quantification with quantified error bounds has been developed at NASA. The package provides implementations for a suite of numerical methods used in uncertainty quantification: Dense tensorization basis methods [3] and a subscale recovery variant [1] for non-smooth data, Sparse tensorization methods[2] utilizing node-nested hierarchies, Sampling methods[4] for high-dimensional random variable spaces.

CFD↗
NASA NTRS2013

Modeling Errors in Daily Precipitation Measurements: Additive or Multiplicative?

The definition and quantification of uncertainty depend on the error model used. For uncertainties in precipitation measurements, two types of error models have been widely adopted: the additive error model and the multiplicative error model. This leads to incompatible specifications of uncertainties and impedes intercomparison and application.In this letter, we assess the suitability of both models for satellite-based daily precipitation measurements in an effort to clarify the uncertainty representation. Three criteria were employed to evaluate the applicability of either model: (1) better separation of the systematic and random errors; (2) applicability to the large range of variability in daily precipitation; and (3) better predictive skills. It is found that the multiplicative error model is a much better choice under all three criteria. It extracted the systematic errors more cleanly, was more consistent with the large variability of precipitation measurements, and produced superior predictions of the error characteristics. The additive error model had several weaknesses, such as non constant variance resulting from systematic errors leaking into random errors, and the lack of prediction capability. Therefore, the multiplicative error model is a better choice.

Modeling↗
NASA NTRSDate not supplied

Use of three-cornered hat error estimates in MERRA-2 to guide an improved reanalysis-Part 1

The three-cornered hat (3CH) method estimates the uncertainties of three different co-located model or observational data sets (Anthes and Rieckh, 2018; Sjoberg et al., 2021). Rieckh et al. (2021) used the 3CH method to compare the random error statistics of different global forecast and reanalysis models, as well as radio occultation (RO) and radiosonde observations. That study showed that the MERRA-2 reanalysis, while having smaller errors in the stratosphere than its predecessor MERRA, had larger errors in the troposphere than many of the other data sets analyzed. The MERRA-2 errors were particularly large in the tropics. In a collaborative effort between UCAR’s COSMIC (Constellation Observing System for Meteorology, Ionosphere and Meteorology) program and NASA’s Global Modeling and Assimilation Office (GMAO), we carried out further 3CH error diagnostics to help isolate the causes of these larger errors and help guide the development of an improved reanalysis. This presentation summarizes random error statistics associated with MERRA-2, ECMWF’s ERA5 reanalysis, and COSMIC-2 (C2) RO observations. We compute 3CH error variance estimates of refractivity, as well as temperature and specific humidity using UCAR’s COSMIC Data Analysis and Archive Center (CDAAC) improved 1D-variational (1D-Var) retrieval (wetPf2) over 15 latitude bands from 45S to 45N. The 1D-Var retrievals of specific humidity and temperature for C2 use NCEP’s Global Forecast System (GFS) as the background. Anthes et al. (2021) showed that it gives accurate estimates of temperature and specific humidity in the tropics and subtropics, even in the challenging environment of intense Hurricane Dorian (2019). This presentation confirms the previous results that MERRA-2 has significantly larger errors in the tropics and subtropics than either C2 or ERA5. Its errors are larger between 30S and 30N compared to 30-45 N-S latitudes, and are also larger over land compared to oceans. Most of the MERRA-2 refractivity errors come from specific humidity, except over land below 3 km where temperature errors are large. These results suggest that moist convection and atmospheric boundary layer physics in MERRA-2 may be responsible for a significant part of the higher uncertainties. These results are being used to guide GMAO in developing an improved next-generation reanalysis, as shown in a companion presentation submitted to this conference (El Akkraoui et al., 2021), which extends this study and describes improvements to MERRA-2 leading to the next GMAO reanalysis.

Jeremiah Sjoberg↗
DOE OSTI2019

Asymptotic convergence of the angular discretization error in the scalar flux computed from the particle transport equation with the method of discrete ordinates

The asymptotic convergence of the angular discretization error in the scalar flux solution of the particle transport equation computed with the Discrete Ordinates (S N ) method with increasing quadrature order is examined. Five selected angular quadrature types are considered: Level Symmetric (LS), Legendre-Chebyshev Quadrangular (LCQ), Legendre-Chebyshev Triangular(LCT), Quadruple Range (QR) and Quadruple Range Spence-type (QRS) quadrature sets. We relate the S N angular discretization error to the quadrature error, and split the total flux into the uncollided flux and the fully collided flux, and then we verify the uncollided scalar flux error and the fully collided scalar flux error separately. After developing the theoretical basis for the relationship between true solution regularity and quadrature rule error, we employ a two-dimensional problem to verify the observed and theoretical convergence orders for the region-averaged uncollided and fully collided scalar flux errors. Numerical results show that the angular discretization errors in the region-averaged scalar flux obtained by different quadrature types converge with different rates, that are commensurate with the regularity order of the exact angular flux within the quadrature-designed integration interval. The angular discretization error in the uncollided region-averaged scalar flux obtained by LC class quadratures converges linearly, and the error obtained by QR class quadrature sets converges quadratically. The angular discretization error in the fully collided region-averaged scalar flux converges linearly for LC class quadratures, and faster-than-second order for QR class quadrature sets.

42 ENGINEERING↗
DOE OSTI2021

Solution Irregularity Remediation for Spatial Discretization Error Estimation for S N Transport Solutions

The discrete ordinates linear Boltzmann transport equation is typically solved in its spatially discretized form, incurring spatial discretization error. Quantification of this error for purposes such as adaptive mesh refinement or error analysis requires an a posteriori estimator, which utilizes the numerical solution to the spatially discretized equation to compute an estimate. Because the quality of the numerical solution informs the error estimate, irregularities, present in the true solution for any realistic problem configuration, tend to cause the largest deviation in the error estimate vis-a-vis the true error. In this paper, an analytical partial singular characteristic tracking (pSCT) procedure for reducing the estimator’s error is implemented within our novel residual source estimator for a zeroth-order discontinuous Galerkin scheme, at the additional cost of a single inner iteration. Here, a metric-based evaluation of the pSCT scheme versus the standard residual source estimator is performed over the parameter range of a Method of Manufactured Solutions test suite. The pSCT scheme generates near-ideal accuracy in the estimate in problems where the dominant source of the estimator’s error is the solution irregularity, namely, problems where the true solution is discontinuous and problems where the true solution’s first derivative is discontinuous and the scattering ratio is low. In problems where the scattering ratio is high and the true solution is discontinuous in the first derivative, the error in the scattering source, which is not converged by the pSCT scheme, is greater than the error incurred due to the irregularity. Ultimately, a pSCT scheme is judged to be useful for error estimation in problems where the computational cost of the scheme is justified. In the presence of many irregularities, such a scheme may be intractable for general use, but in benchmarks, as an analytical tool, or in problems that have nondissipative discontinuities, the scheme may prove invaluable.

73 NUCLEAR PHYSICS AND RADIATION PHYSICS↗
DOE OSTI2023

Perturbative readout-error mitigation for near-term quantum computers

Readout errors on near-term quantum computers can introduce significant error to the empirical probability distribution sampled from the output of a quantum circuit. These errors can be mitigated by classical postprocessing given the access of an experimental response matrix that describes the error associated with the measurement of each computational basis state. However, the resources required to characterize a complete response matrix and to compute the corrected probability distribution scale exponentially with the number of qubits, n . In this work, we modify standard matrix inversion techniques using perturbative approximations with significantly reduced complexity and bounded error when the likelihood of high-order bit-flip events is strongly suppressed. Given a characteristic error rate q , we discuss a method to recover the probability of the all-zeros bit string p 0 by sampling only a small subspace of the response matrix before inverting readout error, resulting in a relative speedup of poly [ 2 n / ( n w ) ] , which we motivate using a simplified error model for which the approximation incurs only O ( q w ) error for some integer w . We then provide a generalized technique to efficiently recover full output distributions with O ( q w ) error in the perturbative limit. These approximate techniques for readout-error correction may greatly accelerate near-term quantum computing applications.

97 MATHEMATICS AND COMPUTING↗
DOE OSTI2026

Resilience of the surface code to error bursts

Quantum error correction works effectively only if the error rate of gate operations is sufficiently low. However, some rare physical mechanisms can cause a temporary increase in the error rate that affects many qubits; examples include ionizing radiation in superconducting hardware and large deviations in the global control of atomic systems. We refer to such rare transient spikes in the gate error rate as error bursts. In this work, we investigate the resilience of the rotated surface code to generic error bursts. We assume that, after appropriate mitigation strategies, the spike in the error rate lasts for only a single syndrome-extraction cycle; we also assume that the enhanced error rate is uniform across the code block. Under these assumptions, and for a circuit-level depolarizing noise model, we perform Monte Carlo simulations to determine the regime in burst error rate and background error rate for which the memory time becomes arbitrarily long as the code block size grows. Our results indicate that suitable hardware mitigation methods combined with standard decoding methods may suffice to protect against transient error bursts in the rotated surface code.

Quantum error correction↗
DOE OSTI2012

A method to evaluate dose errors introduced by dose mapping processes for mass conserving deformations

Purpose: To present a method to evaluate the dose mapping error introduced by the dose mapping process. In addition, apply the method to evaluate the dose mapping error introduced by the 4D dose calculation process implemented in a research version of commercial treatment planning system for a patient case. Methods: The average dose accumulated in a finite volume should be unchanged when the dose delivered to one anatomic instance of that volume is mapped to a different anatomic instance--provided that the tissue deformation between the anatomic instances is mass conserving. The average dose to a finite volume on image S is defined as d{sub S}=e{sub s}/m{sub S}, where e{sub S} is the energy deposited in the mass m{sub S} contained in the volume. Since mass and energy should be conserved, when d{sub S} is mapped to an image R(d{sub S{yields}R}=d{sub R}), the mean dose mapping error is defined as {Delta}d{sub m}=|d{sub R}-d{sub S}|=|e{sub R}/m{sub R}-e{sub S}/m{sub S}|, where the e{sub R} and e{sub S} are integral doses (energy deposited), and m{sub R} and m{sub S} are the masses within the region of interest (ROI) on image R and the corresponding ROI on image S, where R and S are the two anatomic instances from the same patient. Alternatively, application of simple differential propagation yields the differential dose mapping error, {Delta}d{sub d}=|({partial_derivative}d/{partial_derivative}e)*{Delta}e+({partial_derivative}d/{partial_derivative}m)*{Delta}m|=|((e{sub S}-e{sub R})/m{sub R})-((m{sub S}-m{sub R})/m{sub R}{sup 2})*e{sub R}|={alpha}|d{sub R}-d{sub S}| with {alpha}=m{sub S}/m{sub R}. A 4D treatment plan on a ten-phase 4D-CT lung patient is used to demonstrate the dose mapping error evaluations for a patient case, in which the accumulated dose, D{sub R}={Sigma}{sub S=0}{sup 9}d{sub S{yields}R}, and associated error values ({Delta}D{sub m} and {Delta}D{sub d}) are calculated for a uniformly spaced set of ROIs. Results: For the single sample patient dose distribution, the average accumulated differential dose mapping error is 4.3%, the average absolute differential dose mapping error is 10.8%, and the average accumulated mean dose mapping error is 5.0%. Accumulated differential dose mapping errors within the gross tumor volume (GTV) and planning target volume (PTV) are lower, 0.73% and 2.33%, respectively. Conclusions: A method has been presented to evaluate the dose mapping error introduced by the dose mapping process. This method has been applied to evaluate the 4D dose calculation process implemented in a commercial treatment planning system. The method could potentially be developed as a fully-automatic QA method in image guided adaptive radiation therapy (IGART).

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2013

Evaluating IMRT and VMAT dose accuracy: Practical examples of failure to detect systematic errors when applying a commonly used metric and action levels

Purpose: This study (1) examines a variety of real-world cases where systematic errors were not detected by widely accepted methods for IMRT/VMAT dosimetric accuracy evaluation, and (2) drills-down to identify failure modes and their corresponding means for detection, diagnosis, and mitigation. The primary goal of detailing these case studies is to explore different, more sensitive methods and metrics that could be used more effectively for evaluating accuracy of dose algorithms, delivery systems, and QA devices.Methods: The authors present seven real-world case studies representing a variety of combinations of the treatment planning system (TPS), linac, delivery modality, and systematic error type. These case studies are typical to what might be used as part of an IMRT or VMAT commissioning test suite, varying in complexity. Each case study is analyzed according to TG-119 instructions for gamma passing rates and action levels for per-beam and/or composite plan dosimetric QA. Then, each case study is analyzed in-depth with advanced diagnostic methods (dose profile examination, EPID-based measurements, dose difference pattern analysis, 3D measurement-guided dose reconstruction, and dose grid inspection) and more sensitive metrics (2% local normalization/2 mm DTA and estimated DVH comparisons).Results: For these case studies, the conventional 3%/3 mm gamma passing rates exceeded 99% for IMRT per-beam analyses and ranged from 93.9% to 100% for composite plan dose analysis, well above the TG-119 action levels of 90% and 88%, respectively. However, all cases had systematic errors that were detected only by using advanced diagnostic techniques and more sensitive metrics. The systematic errors caused variable but noteworthy impact, including estimated target dose coverage loss of up to 5.5% and local dose deviations up to 31.5%. Types of errors included TPS model settings, algorithm limitations, and modeling and alignment of QA phantoms in the TPS. Most of the errors were correctable after detection and diagnosis, and the uncorrectable errors provided useful information about system limitations, which is another key element of system commissioning.Conclusions: Many forms of relevant systematic errors can go undetected when the currently prevalent metrics for IMRT/VMAT commissioning are used. If alternative methods and metrics are used instead of (or in addition to) the conventional metrics, these errors are more likely to be detected, and only once they are detected can they be properly diagnosed and rooted out of the system. Removing systematic errors should be a goal not only of commissioning by the end users but also product validation by the manufacturers. For any systematic errors that cannot be removed, detecting and quantifying them is important as it will help the physicist understand the limits of the system and work with the manufacturer on improvements. In summary, IMRT and VMAT commissioning, along with product validation, would benefit from the retirement of the 3%/3 mm passing rates as a primary metric of performance, and the adoption instead of tighter tolerances, more diligent diagnostics, and more thorough analysis.

61 RADIATION PROTECTION AND DOSIMETRY↗
DOE OSTI2015

SU-E-T-363: Error Detection Comparison of EPID and MLC Log File Based IMRT QA Systems

Purpose: In this study we will compare the ability of three QA methods (Delta4, MU-EPID, Dynalog QA) to detect specific errors. Methods: A Varian Novalis Tx with a HD120 MLC and aS1000 Electronic Portal Imaging Device (EPID) was used in our study. Multi-leaf collimator (MLC) errors, gantry angle and dose errors were introduced into 5 volumetric arc therapy (VMAT) plans. 3D dose distributions calculated with data from the EPID and Dynalog QA methods were compared with the planned dose distribution. The gamma passing percentages as well as percentage error of planning target volume (PTV) dose were used for passing determination. Baselines for gamma passing percentages and PTV dose were established by measuring the original plan 5 times consecutively. Standard passing thresholds as well as thresholds derived from receiver operator characteristic (ROC) analysis and 2 standard deviation (SD) criteria were used. Results: When applying the standard 95% pass rate at 3%/3mm gamma analysis 14, 21 and 8 of 30 errors were detected by the Delta4, MU-EPID and Dynalog QA methods respectively. Thresholds set at 2 SD from our base line measurements resulted in the detection of 18, 9 and 14 of 30 errors for the Delta4, MU-EPID and Dynalog QA methods respectively. When using D2 of the PTV as a metric the Dynalog QA detected 20 of 30 errors while the EPID method detected 14 of 30 errors. Using D98 of the PTV, Dynalog QA detected 13 of 30 while the EPID detected 3 of 30 errors. Conclusion: Although MU-EPID detected the most errors at the standard 95% cutoff it also produced the most false detections in the baseline data. The Dynalog QA was the most effective when the ROC adjusted passing threshold was used. D2 was more effective as a metric for detecting errors than D98.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

TH-B-BRC-00: How to Identify and Resolve Potential Clinical Errors Before They Impact Patients Treatment: Lessons Learned

Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews of some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2016

TH-B-BRC-01: How to Identify and Resolve Potential Clinical Errors

Radiation treatment consists of a chain of events influenced by the quality of machine operation, beam data commissioning, machine calibration, patient specific data, simulation, treatment planning, imaging and treatment delivery. There is always a chance that the clinical medical physicist may make or fail to detect an error in one of the events that may impact on the patient’s treatment. In the clinical scenario, errors may be systematic and, without peer review, may have a low detectability because they are not part of routine QA procedures. During treatment, there might be errors on machine that needs attention. External reviews of some of the treatment delivery components by independent reviewers, like IROC, can detect errors, but may not be timely. The goal of this session is to help junior clinical physicists identify potential errors as well as the approach of quality assurance to perform a root cause analysis to find and eliminate an error and to continually monitor for errors. A compilation of potential errors will be presented by examples of the thought process required to spot the error and determine the root cause. Examples may include unusual machine operation, erratic electrometer reading, consistent lower electron output, variation in photon output, body parts inadvertently left in beam, unusual treatment plan, poor normalization, hot spots etc. Awareness of the possibility and detection of error in any link of the treatment process chain will help improve the safe and accurate delivery of radiation to patients. Four experts will discuss how to identify errors in four areas of clinical treatment. D. Followill, NIH grant CA 180803.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2015

Clover: Compiler directed lightweight soft error resilience

This paper presents Clover, a compiler directed soft error detection and recovery scheme for lightweight soft error resilience. The compiler carefully generates soft error tolerant code based on idem-potent processing without explicit checkpoint. During program execution, Clover relies on a small number of acoustic wave detectors deployed in the processor to identify soft errors by sensing the wave made by a particle strike. To cope with DUE (detected unrecoverable errors) caused by the sensing latency of error detection, Clover leverages a novel selective instruction duplication technique called tail-DMR (dual modular redundancy). Once a soft error is detected by either the sensor or the tail-DMR, Clover takes care of the error as in the case of exception handling. To recover from the error, Clover simply redirects program control to the beginning of the code region where the error is detected. Lastly, the experiment results demonstrate that the average runtime overhead is only 26%, which is a 75% reduction compared to that of the state-of-the-art soft error resilience technique.

97 MATHEMATICS AND COMPUTING↗
NASA NTRS2012

Performance Data Errors in Air Carrier Operations: Causes and Countermeasures

Several airline accidents have occurred in recent years as the result of erroneous weight or performance data used to calculate V-speeds, flap/trim settings, required runway lengths, and/or required climb gradients. In this report we consider 4 recent studies of performance data error, report our own study of ASRS-reported incidents, and provide countermeasures that can reduce vulnerability to accidents caused by performance data errors. Performance data are generated through a lengthy process involving several employee groups and computer and/or paper-based systems. Although much of the airline indUStry 's concern has focused on errors pilots make in entering FMS data, we determined that errors occur at every stage of the process and that errors by ground personnel are probably at least as frequent and certainly as consequential as errors by pilots. Most of the errors we examined could in principle have been trapped by effective use of existing procedures or technology; however, the fact that they were not trapped anywhere indicates the need for better countermeasures. Existing procedures are often inadequately designed to mesh with the ways humans process information. Because procedures often do not take into account the ways in which information flows in actual flight ops and time pressures and interruptions experienced by pilots and ground personnel, vulnerability to error is greater. Some aspects of NextGen operations may exacerbate this vulnerability. We identify measures to reduce the number of errors and to help catch the errors that occur.

countermeasures↗
DOE OSTI2018

Dosimetric impact of translational and rotational setup errors for spine stereotactic body radiotherapy: A phantom study

This study aimed to investigate experimentally the effect of translational and rotational setup errors on 3-dimensional dose distributions by using the gamma index and dose volumetric indices for spine stereotactic body radiotherapy. Treatment plans were designed in accordance with the Radiation Therapy Oncology Group (RTOG) 0631 protocol. Measurements were taken using a Delta4 phantom (ScandiDos, Uppsala, Sweden). Setup errors were generated using the HexaMotion 6D moving platform (ScandiDos). Dose distributions in the presence of setup errors were evaluated, according to the γ passing rate with the 3% and 2 mm criteria (γ{sub 3%/2 mm}) and dose volumetric indices (D{sub 90} for the target volume and D{sub 2} for the spinal cord), using the Delta4 device (ScandiDos). The sensitivity coefficient, which represented the correlation between the γ{sub 3%/2 mm} passing rate and dose volumetric indices, was determined to assess robustness against setup errors. Rotational setup errors of 2° were equivalent to translational setup errors of 2 mm for the γ{sub 3%/2 mm} passing rate, D{sub 90} for the target, and D{sub 2} for the spinal cord. D{sub 90} for the target had low robustness against a translational setup error in the vertical direction and a rotational setup error in the pitch direction. D{sub 2} for the spinal cord was sensitive to a translational setup error in the lateral direction and a rotational setup error in the roll direction. The positioning accuracy of the rotational setup error, corresponding to the tolerance level of image-guided radiotherapy in the RTOG 0631 protocol, was required to be ≤ 2°.

62 RADIOLOGY AND NUCLEAR MEDICINE↗
DOE OSTI2014

SU-E-T-310: Targeting Safety Improvements Through Analysis of Near-Miss Error Detection Points in An Incident Learning Database

Purpose: Radiation treatment planning involves a complex workflow that can make safety improvement efforts challenging. This study utilizes an incident reporting system to identify detection points of near-miss errors, in order to guide our departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or their patterns. Methods: 1377 incidents were analyzed from a departmental nearmiss error reporting system from 3/2012–10/2013. All incidents were prospectively reviewed weekly by a multi-disciplinary team, and assigned a near-miss severity score ranging from 0–4 reflecting potential harm (no harm to critical). A 98-step consensus workflow was used to determine origination and detection points of near-miss errors, categorized into 7 major steps (patient assessment/orders, simulation, contouring/treatment planning, pre-treatment plan checks, therapist/on-treatment review, post-treatment checks, and equipment issues). Categories were compared using ANOVA. Results: In the 7-step workflow, 23% of near-miss errors were detected within the same step in the workflow, while an additional 37% were detected by the next step in the workflow, and 23% were detected two steps downstream. Errors detected further from origination were more severe (p<.001; Figure 1). The most common source of near-miss errors was treatment planning/contouring, with 476 near misses (35%). Of those 476, only 72(15%) were found before leaving treatment planning, 213(45%) were found at physics plan checks, and 191(40%) were caught at the therapist pre-treatment chart review or on portal imaging. Errors that passed through physics plan checks and were detected by therapists were more severe than other errors originating in contouring/treatment planning (1.81 vs 1.33, p<0.001). Conclusion: Errors caught by radiation treatment therapists tend to be more severe than errors caught earlier in the workflow, highlighting the importance of safety checks in dosimetry and physics. We are utilizing our findings to improve manual and automated checklists for dosimetry and physics.

60 APPLIED LIFE SCIENCES↗
DOE OSTI2014

SU-E-T-613: Dosimetric Consequences of Systematic MLC Leaf Positioning Errors

Purpose: The purpose of this study is to determine the dosimetric consequences of systematic MLC leaf positioning errors for clinical IMRT patient plans so as to establish detection tolerances for quality assurance programs. Materials and Methods: Dosimetric consequences were simulated by extracting mlc delivery instructions from the TPS, altering the file by the specified error, reloading the delivery instructions into the TPS, recomputing dose, and extracting dose-volume metrics for one head-andneck and one prostate patient. Machine error was simulated by offsetting MLC leaves in Pinnacle in a systematic way. Three different algorithms were followed for these systematic offsets, and are as follows: a systematic sequential one-leaf offset (one leaf offset in one segment per beam), a systematic uniform one-leaf offset (same one leaf offset per segment per beam) and a systematic offset of a given number of leaves picked uniformly at random from a given number of segments (5 out of 10 total). Dose to the PTV and normal tissue was simulated. Results: A systematic 5 mm offset of 1 leaf for all delivery segments of all beams resulted in a maximum PTV D98 deviation of 1%. Results showed very low dose error in all reasonably possible machine configurations, rare or otherwise, which could be simulated. Very low error in dose to PTV and OARs was shown in all possible cases of one leaf per beam per segment being offset (<1%), or that of only one leaf per beam being offset (<.2%). The errors resulting from a high number of adjacent leaves (maximum of 5 out of 60 total leaf-pairs) being simultaneously offset in many (5) of the control points (total 10–18 in all beams) per beam, in both the PTV and the OARs analyzed, were similarly low (<2–3%). Conclusions: The above results show that patient shifts and anatomical changes are the main source of errors in dose delivered, not machine delivery. These two sources of error are “visually complementary” and uncorrelated (albeit not additive in the final error) and one can easily incorporate error resulting from machine delivery in an error model based purely on tumor motion.

60 APPLIED LIFE SCIENCES↗