RADIATION SAFETY !

Radiation Safety

Kyle Garafolo

University of Wisconsin - La Crosse

DOS 516: Fundamentals of Radiation Safety

October 18, 2018

RADIATION SAFETY !2

Radiation Therapy is one of the essential components of an effective cancer care

program. It is estimated that approximately 38.4% of men and women in the United States, or
about 1 in 2.6, will be diagnosed with cancer at some point in their lifetime.1 Of those
individuals, nearly half would benefit from radiation therapy as a means to cure or palliate their
disease.2 However, as with most medical procedures, radiation therapy is not without risks. Due
to several past high profile incidents of medical errors in radiation oncology departments, the
public understandably has growing concerns about the safety of radiation therapy treatments.
While these concerns certainly are not without merit, radiotherapy is still considered to be a very
safe medical practice. Excellent patient safety and quality are among the primary goals that
radiation oncology professionals and organizations strive to achieve. With proper knowledge
about radiation safety initiatives taken in radiation oncology departments, the public should not
fear radiation as a medical treatment option. These initiatives and best practices will be discussed
in greater detail.
Radiation therapy is regulated at both the federal and (in most cases) state level. This
profession is regarded as one of the most highly regulated medical practices.3 Yet, despite these
strict regulations, radiation errors can and do unfortunately happen. Understanding the exact
cause and frequency of radiation oncology errors is a challenging task, however. Between
misadministration, adverse effects, medical events, near misses and the like, the definition of a
radiation “error” can be equivocal in nature and underreporting is common.4 A 2008 study by the
World Health Organization5 estimated that the risk of mild to moderate injurious patient
outcomes was about 1,500 per 1 million treatment courses. In comparison, the incidence of
hospitalization due to adverse drug reactions was about 65,000 per 1 million, indicating that
radiotherapy is still a very safe medical procedure.5 Despite this information, every effort should
be made to reduce the risk of accidental radiation exposure and keep radiation therapy treatments
as safe as possible.
Following the media release describing various radiation oncology medical events,
radiation oncology professionals determined action needed to be taken to address these growing
concerns. In a 2010 meeting titled, “Safety in Radiation Therapy: A call to Action,” which was
sponsored by the American Association of Physicists in Medicine (AAPM) and the American
RADIATION SAFETY !3

Society of Radiation Oncology (ASTRO), participants undertook the daunting task of

determining the root cause of mistakes and equipment errors in radiation oncology as well as
finding possible solutions to make the field safer.6 The treatment of cancer patients with radiation
is a very complex task, and as such, is a core element to radiation oncology errors.
Some reasons for this complexity include: the nature of the patient’s disease, the highly
sophisticated technologies used, the dependence on proper staff communication, and the
involvement of humans with varying levels of skill and competency throughout the treatment
process.6 In addition to complexity, some other common causes for errors identified were:
dependence on computer-aided design of treatment plans / computer controlled treatment
machines; cluttered therapy workstations with numerous computer monitors; staff interruptions /
extraneous conversations at the treatment console; insufficient warning notifications for therapist
if something was out of tolerance or incorrect; poor quality supervision or incorrect machine
calibration by physicist; poor equipment training / education; lack of policies and procedures
defining treatment team processes / responsibilities; and lack of awareness to patient day-to-day
progress.6 Identifying the cause of errors was a crucial step toward helping make radiation
oncology a safer medical environment. The next task was to evaluate these causes and establish a
comprehensive set of solutions.
Over the course of several years, various distinguished professional organizations,
including the aforementioned 2010 meeting attendees, developed a thorough set of solutions and
safety initiatives. Dunscombe7 evaluated and analyzed these recommendations and developed an
all-inclusive list, sorted by most referenced to least:
• Training - Education and training curricula should include intensive focus on quality and
safety related issues, including human factors and process flow
• Staffing / Skills Mix - Complex technology and procedures require proper staffing by all
members of the radiation oncology team
• Documentation / Standard Operating Procedures - Proper documentation, familiarity, and
adherence to standard operating procedures and policies
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• Voluntary incident learning system - Tracking, analyzing, and sharing information,

preferably across institutions, on radiotherapy events prove beneficial and promote maximum
opportunities for learning
• Communication / Questioning - Clear, unambiguous open communication and respectful
questioning are critical components to a safe culture within an organization
• Check Lists - Using checklists as part of a quality control and treatment delivery process is
likely to reduce the potential for errors in radiation oncology departments
• Quality Control and Preventative Maintenance - The AAPM and other professional
organizations suggest the quality control of equipment, such as through Task Group 100
• Dosimetric Audit - Occasional independent dosimetric audits should be performed focusing
on quality, accuracy, and safety within the radiation oncology department
• Accreditation - Radiation oncology specific accreditation should be attained to help
demonstrate facilities’ commitment to the highest quality and safety standards
• Minimizing Interruptions - Traffic near treatment consoles should be minimized, as should
unnecessary conversations and noise
• Prospective Risk Assessment - Methods to identifying potential errors and safety measures
should be promoted, as evidenced by failure mode effects analysis and root cause analysis
• Safety Culture - Commitment from all members of the organization to patient safety, even if
it means allocating resources to address safety issues.
Radiation safety will always be a top priority in all radiation oncology departments.
While medical errors unfortunately do occur, the incidence in the field of radiation oncology still
remains among the best in healthcare. Many systems are in place to ensure the highest safety and
quality standards are met. Radiation therapy is a highly complex field of medicine, but advances
in technology have helped reduce the potential for errors tremendously. Transitioning to a culture
of safety and following the aforementioned recommendations will only further emphasize the
claim that radiation oncology is still a very safe medical field.
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Reference List

1. Cancer Statistics. National Cancer Institute at the National Institute of Health. https://
www.cancer.gov/about-cancer/understanding/statistics. Updated April 27, 2018. Accessed
October 18, 2018.
2. Jaffray DA, Gospodarowicz MK. Radiation Therapy for Cancer. In: Gelband H, Jha P,
Sankaranarayanan R, et al., editors. Cancer: Disease Control Priorities, Third Edition
(Volume 3). Washington (DC): The International Bank for Reconstruction and
Development / The World Bank; 2015 Nov 1. Chapter 14. Available from: https://
www.ncbi.nlm.nih.gov/books/NBK343621/ doi: 10.1596/978-1-4648-0349-9_ch14
3. Marks L, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation oncology.
Practical Radiat Oncol. 2011;1(1):2-14.
4. Errors in Radiation Therapy. Pennsylvania Patient Safety Advisory. 2009;6(3):87-92.
http://patientsafety.pa.gov/ADVISORIES/documents/200909_87.pdf.
Published September, 2009. Accessed October 18, 2018.
5. World Health Organization. Radiotherapy risk profile: Technical manual. Geneva,
Switzerland: WHO Publishing; 2008.
6. Hendee W, Herman M. Improving patient safety in radiation oncology. Journal of Medical
Physics. 2011;38(1)78-82. DOI: 10.1118/1.3522875. Accessed October 18, 2018.
7. Dunscombe P. 2012. Recommendations for safer radiotherapy: what’s the message? Front.
Oncol. 2:129. doi: 10.3389/fonc.2012.00129