Yinan Wang

Dos 516-Fundamentals of Radiation Safety

October 21, 2015

Patient Safety in Radiation Oncology

Statistics from the National Cancer Institute show that more than half of all cancer patients
receive radiation therapy during their treatment courses.1 Radiation therapy has been proved
effective in treating cancer patients, while it can cause severe consequences if misadministrations
occur. Recently a series of incidences of overdosing patients has made the public overly worried
about radiotherapy, especially after the New York Times reporting on two tragic accidents of
fatal overdosing.2 Despite many lives radiation therapy have saved, news and public seem to
only focus on the negative aspects and neglect the fact that radiation therapy has become much
safer than before as technology advances and serious accidents are rare.1
In order to improve patient safety, multiple quality control methods have been developed by
national and international organizations and implemented in radiation oncology departments in
the United States to prevent, identify, and correct human errors and equipment failures.1 For
example, at Beaumont hospital, these methods include weekly new patients chart run to review
patient information and treatment plans. Before an actual treatment, the treatment plan has to be
signed by both the physician and physicist and checked against the corresponding site boarding
pass. Portal and/or cone beam imaging are taken to make sure the treatment site and patient setup
are accurate before the treatment. For some special procedures, like stereotactic radio surgeries,
both the physicist and physician have to be on site to proof the treatment setting and image
registration. In-vivo dosimetry during external beam radiation therapy is taken to verify patient
dose in real time. Physicians will check daily cone beam image to verify tumor changes; a
physicist will do weekly chart check to identify any change in prescriptions, plans, and
treatments.
To further uncover less usual errors that can occur anywhere in the whole planning and treatment
process, the radiation oncology department at the Johns Hopkins Hospital (Baltimore) has
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implemented a series of strategies including Failure Mode and Effects Analysis (FMEA), riskreduction interventions, and voluntary error and near-miss reporting systems.1 They broke down
the whole radiation therapy process into four sub-processes (consult, simulation, treatment
planning, and treatment) and 269 steps in total. Then they analyzed possible errors that may
occur in each sub-process and determined risk probability level for each error or potential failure
mode by giving each error a score. This process that identifies potential hazards before actual
damage occurs to patients is called FMEA. For the top 15 potential failure modes with highest
scores, they designed corresponding solutions to prevent the errors, the process of which is called
risk-reduction interventions. If errors or near-miss incidents have already occurred, they report
the incidents to a voluntary error and near-miss reporting system which is a web-based database
and can be used by any member in the department. Collecting and analyzing these errors and
near-misses provided very valuable information to improve safety and quality of radiotherapy.
Radiation therapy is very complicated due to the complexity of the diseases and the involvement
of sophisticated technologies and humans throughout the treatment process. Since more steps
means higher probability of errors, radiotherapy with 269 steps is more likely to have higher
error rate in comparison to those processes with less steps. Although many potential errors have
been imagined or predicted by the staff in the radiation oncology department at the Johns
Hopkins Hospital (Baltimore), they still found that 42% of the actual reported errors were not
within the potential error list by the FMEA.1 Thus the error and near-miss reporting system is
essential and can work together with FMEA to improve patient safety.
The American Society for Therapeutic Radiology and Oncology (ASTRO) and the American
Association of Physicists in Medicine (AAPM) have realized the importance of a national error
reporting system. On June 19, 2014, ASTRO and AAPM launched a national error reporting
program, the Radiation Oncology Incident Learning System (RO-ILS), through which
participants across the U.S. can report all errors, near misses, and deviations and then analyze the
data and design the corresponding corrections of the incidents.3 The Radiation Oncology Health
Advisory Council, composed of three radiation oncologists, three physicists, one administrator,
and one dosimetrist who would like volunteer for 1-2 years service, takes charge of the
collecting and analyzing of the data. 320 incidents have been input into the RO-ILS by 70
participated sites until February 2015. This information shared among the field of radiation
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oncology provides valuable actual experience that leads to the customizations of the practical
solutions and guidances to improve safety and quality of radiotherapy. The RO-ILS has been
proved to be effective in reducing the rate of incidents in radiation treatment.
Although the process of radiation treatment is complex that involves many steps, the actual or
observed error rates in radiation therapy processes are much lower if taking into consideration of
the number of steps involved.1 Tremendous efforts have been and will continue to be made to
reduce the incidents and enhance patient safety. With strict safety measures and strategies being
implemented in the profession of radiation therapy, the risk of errors has been minimized and
patient safety can be greatly assured.
References
1. 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.
2. Bogdanich W. Radiation Offers New Cures, and Ways to Do Harm. The New York Times.
http://www.nytimes.com/2010/01/24/health/24radiation.html?_r=1. Published January 23,
2010. Accessed October 20, 2015.
3. Evans SB. Patient safety across disciplines: radiation oncology incident learning system. J
Oncol Pract. 2015;11(3):202-203. doi:10.1200/JOP.2015.004341.