MUNA AHMED 1

PROF. RAKESH PATEL

FUNDEMENTAL OF RADIATION SAFETY
DECEMBER 4, 2023

Ensuring Radiation Safety in Clinical Practice

Radiation oncology has emerged as a cornerstone discipline in the management and
eradication of cancer for more than 50% of cancer patients each year due to technological
advancements 3. Managing the care of the growing number of patients has required a strict
adherence to the national and institutional established polices which ensures the prescribed dose
is delivered with less than 5% uncertainty2. Given the number of variables and uncertainties
inherent in daily practice, each radiation oncology implements a multi-disciplinary quality
assurance program. Licensure and registration of any radioactive material and equipment further
span the dedication to the safety of patients, workers, and the general public. Additionally, the
oversight spans from institutional radiation safety committee, Nuclear Regulatory Commission
and advisory committees such as the National Committee of Radiation Protection guarantee
meticulous adherence to federal law and institutional policies. Every medical event or suspicion
of mistreatment is thoroughly investigated. This persistent dedication to safe practice ensures the
safety of patients and the general public equally.
In radiation oncology technology advancements such as the introduction of multi-leaf
collimations (MLC) have led to the introduction of intensity-modulated radiation therapy (
IMRT)2. IMRT allows for a sharp dose gradient that maximizes the prescribed dose to the tumor
volume while mitigating the dose to normal healthy structures around it2. With this, a host of
tests on the planning equipment, treatment machines, and patient plan-specific, imaging quality
must be tested periodically to ensure comprehensive safety and limit uncertainty.
Treatment planning is the first crucial step to ensure the accuracy of delivered treatments
is a precise translation of the calculated dose and MLC leaf sequence to the treatment delivery
machines2. The mechanical limitation of how fast each leaf can move must be understood and
each plan must be tested to compare the calculated plan to what is delivered. Other aspects such
as the integrity of the imaging data for planning, heterogeneity correction, and the calculated
relative dose distribution must be tested2. In addition, due to the many mechanics needed to
deliver one treatment, the accelerator must be tested to ensure an accurate synchronized motion
between the accelerator's speed with MLC motion and the correct radiation output2. This inherent
self-check allows for the machine to stop delivering doses if one of the components is not in sync
 2

entirely to permanently avoid overdosing patients during treatment2. The emergence of imaging
has become an invaluable tool to enhance the precision of each treatment. Various imaging
techniques such as image-guided radiation therapy (IGRT) allow for patient position to be
verified before treatment, while others, like portal imaging, confirm not only patient alignment
but the actual treatment field2. More sophisticated programs allowed for constant imaging during
treatment to detect any deviation known as intra-fractional monitoring (IMR)2. Lastly, adaptive
planning based on the current Cone Beam Computer Tomography(CBCT) taken of the patient
can be implemented to ensure any internal variation is addressed before treatment2.
Despite the rare occurrence of catastrophic events sensationalized by the media, the
public concern for the safety of radiation oncology continues. The rigorous testing of the
mechanical aspect of radiation oncology is only the first step in intra-disciplinary quality
assurance and risk-reducing strategies implemented by radiation oncology3. In a publication by
Terezakis SA et al, an internal review reported an error rate of 0.4%( 17 out of 4227 patients)
which encouraged further improvement of established workflows 3. This publication advocates
for a nationwide safety initiative, advocating for the creation of a standardized radiation
oncology workflow. Additionally, Terezakis SA et al propose and implement a voluntary
intradepartmental error and near-miss reporting system 3. These measures inherently aim to
improve safety standards within the radiation oncology department.
Terezakis SA et al article delves into enhancing professional training by proposing a
national voluntary error reporting system to collect errors and near misses3. While many
departments have institutional-based reporting systems to improve clinical workflow and the
safety of patients, a national database can allow smaller clinics to identify common errors and
apply them to their departmental training. Furthermore, Terezakis SA et al advocates for a
standardized definition of error and near miss across radiation oncology departments to establish
a universal language for better communication3.
This study identifies a total of 270 steps taken in a radiation oncology department from
simulation to treatment and has marked a substantially low error rate, with many steps being
nearly 99.9% error-proof3. This can be attributed to not only the mechanical and treatment
planning QA, but also weekly intra-professional peer review conferences, verification of patient
setup utilizing both inter and intrafraction monitors, and radiation dose checks utilizing diode3.
 3

Moreover, emerging strategies now being explored and implemented by many radiation
oncology departments include utilizing failure mode and effects analysis (FEMA) which takes a
proactive approach to identify any errors that can occur in radiation oncology3. When each error
that could occur is identified, a risk reduction is implemented to intervene in any errors identified
by the FEMA analysis3. The article emphasizes deleting unused CT scans and correctly labeling
CT scans, double and cross-checking the correct plan is moded up, exporting correct verification
images, and photographing patients' marks for reference during setup3. Each area highlighted
above serves as a reminder of improvements that each radiation oncology strives to achieve by
implementing an institution standard labeling system, physician-approved CT scans being
imported to planning systems, barcodes as part of patient identity verification, and a
computerized record and verification system.
Radiation oncology's ongoing commitment to identifying errors and reducing
uncertainties creates a transparent environment that actively cultivates trust between
professionals and the general public. The rare but impactful catastrophic events witnessed by the
public serve as a reminder of the potential risks when proper precautions aren't followed. The
commission of technological advancements in radiation oncology strives to limit uncertainties in
patient treatment to below 5% for each patient in our care2. Furthermore, the thorough dedication
of each professional in quality assurance programs, continual training, and federal laws allows us
to optimize patient care while reducing risk. Overall, the oversight amplifies the commitment to
ensure public safety.
 4

Citation:

1. Lenards, N. Regulations. Lecture nodes. SoftChalk. La Crosse, WI: UW-L Medical

Dosimetry Program; Content 2023. Accessed December 3, 2023,
https://www.softchalkcloud.com/lesson/serve/XarfVLNvFAtYJb/html

2. Palta JR, Liu C, Li JG. Quality assurance of intensity-modulated radiation therapy. Int J
Radiat Oncol Biol Phys. 2008;71(1 Suppl):S108-S112. Accessed December 3, 2023,
doi:10.1016/j.ijrobp.2007.05.092

3. Terezakis SA, Pronovost P, Harris K, Deweese T, Ford E. Safety strategies in an

academic radiation oncology department and recommendations for action. Jt Comm J
Qual Patient Saf. 2011;37(7):291-299. Accessed December 3,
2023doi:10.1016/s1553-7250(11)37037-7