Jennifer DeWeese

University of Wisconsin – La Crosse

DOS 516 – Fundamentals of Radiation Safety

December 5, 2022

Radiation Oncology -Patient Safety

Radiation is a pivotal modality in treating patients with cancer. High doses of radiation

can kill cancer cells or slow the growth by damaging the cell’s DNA in the tumor. With such

high doses comes great responsibility with precision and accuracy. Mistakes in radiation

therapy could cause serious injuries or even death.

There have been a handful of terrible radiation accidents that have resulted in deaths.

When these incidents are publicized in the press the public starts to worry. According to the

New York Times, two patients died after being exposed to too much radiation in 2007. The first

instance involved a man who was being treated for head and neck cancer in a New York City

hospital. Healthcare providers had failed to detect a computer malfunction that directed a

linear accelerator to send radiation beams straight to the patient’s brain stem and neck. The

mistake went on for three consecutive days, the results were fatal. The second case was that of

a woman with breast cancer. The patient received three times the amount of radiation

intended for her treatments because of a missing filter in the linear accelerator. The overdose

left a painful hole in her chest which she later died from. 1

With these published articles surfacing and the public becoming more aware of medical

mistakes a meeting was called to order by the American Association of Physicists in Medicine

and the American Society of Radiation Oncology in 2010. The topic was Safety in Radiation

Therapy: A Call to Action. “Errors are bound to happen with the complexity of the disease, the

sophistication of the technologies employed, the intricacies of communication among members

of the treatment team, and probably foremost, the involvement of humans throughout the

treatment regium. For these reasons the practice of radiation oncology includes several quality

control steps designed to detect and correct mistakes and equipment failures before they

negatively impact the well-being of patients.”2

Many parties were included in the meeting; medical physicist, administrators, radiation

oncologists, radiation therapists, dosimetrist, radiation oncology venders and regulators.

Presentations and discussions described several causes of potential errors in radiation

oncology, including our dependency on computer-aided technologies. Other examples were

cluttered workspaces, too many monitors with too many vendors that aren’t integrated well,

staff traffic in control rooms, inadequate warning systems to alert if parameters are outside of

normal tolerances, inattention of medical staff in the day-to-day progress of patients,

inaccurate machine calibrations, failure of manufacturers to respond to treatment equipment

issues, educational short comings, the lack of policies and procedures defining treatment

processes and responsibilities of the treatment team. 2

The American Society of Radiation Oncology responded to these issues with a six-point

action plan for improving quality of treatment and reducing errors:

 Creation of an anonymous national database for event reporting

 Enhance and accelerate the ASTRO/ACR Practice Accreditation Program
 Expand education and training programs to include intensive focus on quality
 and safety
 Develop tools for cancer patients to use in discussions with radiation oncologists
 Accelerate development of the IHE-RO (Integrated Health Enterprise—Radiation
 Oncology) program
 Advocate for passage of the CARE (Consistency, Accountability, Responsibility,
 Excellence in Medical Imaging and Radiation Therapy) act 2

The meeting generated many recommendations going forward for all those in the field:
  Simplify and streamline treatment machine and equipment
 Workstations should be clutter free
 Therapists should have an overall better understanding of how everything works
 Provide early warnings and alerts
 Vendors should address concerns reported by all radiation team members
 AAPM and ASTRO should have user group meetings where vendors and users
 can have open discussions on operational issues
 Simplify the billing process
 Develop recommended staffing levels
 Radiation therapy facilities should employ techniques such as failure mode
 effects analysis (FMEA) to identify potential sources of error and root-cause
 analysis (RCA) to identify and correct errors when they occur
 Develop an error reporting system
 Commented [GTJM1]: How what?
 A covenant and commitment to safety should be expected of the treatment
 team
 Any member of the treatment team can declare a Time Out
 Check lists need to be in place
 Audits should be performed
 Facility accreditation should be attained
 Standard operating procedures should be available and revised as necessary
 Patient safety should be a competency
 Safety champions should be present
 Treatment team qualifications must be consistent and recognized nationally
 The FDA review process should be improved.2

Although radiation offers many benefits to those with cancer, it does come at a risk. It is

important for the public to realize that many initiatives have been taken to improve the safety of

radiation oncology. “Today's RT has evolved into a multistep process involving numerous systems

communicating with one another through a complex network of software, hardware, and human

interfaces, which require a meticulous coordination and attention to detail to facilitate the accurate
delivery of the planned treatment.”3

1. Bogdanich, W. (2010). Radiation offers new cures, and ways to do harm. New York Times, 23,
A1.
2. Hendee, W. R., & Herman, M. G. (2011). Improving patient safety in radiation oncology.
Medical physics, 38(1), 78-82.
3. Joshi, C. P. (2014). Patient safety in an environment of rapidly advancing technology in radiation
therapy. Journal of medical physics, 39(2), 61