Radiation Safety in Radiation Oncology

Tamara S. Eng
October 21, 2015

After recent incidences of overdosing patients, the public seems worried about radiation
exposure. This is understandable after reading articles such as Radiation Offers New Cures, and
Ways to Do Harm in The New York Times. This article focuses on radiation overdosing errors
of two patients, which caused their deaths.1 While this article brings to light the potential
catastrophic danger radiation therapy can have, it is important to note that these errors are rare
and that the majority of treatments are safe, as well as, effective.2 Radiation safety is not taken
lightly by radiation oncology professionals. Most facilities have taken steps toward improving
radiation safety going beyond the legally required safety precautions. Given the rare occurrence
of grave errors and the stringent radiation safety measures taken by radiation oncology
departments, the public should not be concerned for their general safety regarding radiation.
One method to improve radiation safety is a program called crew resource management
(CRM). CRM includes training in teamwork, communication, checklists, specific protocols, and
algorithms.3 Its purpose is to decrease accidents caused by human error and poor teamwork.3
CRM includes four pillars: patient identification methods, pause for the cause, enabling all
staff to halt treatment and question decisions, and daily morning meetings.3 Patient identification
includes cross-checking information between two radiation oncology personnel before a
treatment begins. Pause for the cause is the process of confirming that everything is as it
should be prior to administering the treatment.3 This pillar encourages patients to voice concerns
regarding anything with which they are not comfortable.3 There are also linear accelerator
treatment guides, which delineate the required items to be cross-checked before the patient enters
the treatment room, after the patient is in the treatment room, and after treatment delivery. This
standardization allows any radiation therapist to accurately and safely treat every patient. If any
team member, regardless of hierarchy, recognizes something is not as it should be, they are to
halt the process.3 Staff meetings allow safety concerns to be voiced and facilitate open
communication between physicists, dosimetrists, radiation therapists, social workers, physicians,
and other staff. CRM greatly improves the safety within the radiation oncology department.
Another method to increase radiation safety involves risk identification strategies.2
Prospective risk assessment (PRA) methods work to identify potential errors in a specific
setting.2 John Hopkins University employed Failure Mode and Effects Analysis (FMEA) in
which both clinicians and administrators identify possible errors that could happen during a
particular treatment. This PRA method identifies risks before treatment, thus preventing patients

from experiencing related negative effects.2 One example of a PRA involves the error of a
radiation treatment plan being pulled up at the computer console for the incorrect patient. The
hospital implemented a standard procedure including patient identification cards with patient
specific barcodes. Before treatment, the radiation therapist scans the barcode into the computer.
The computer is programed to pull up the specific patients treatment plan. Furthermore, as an
identification double check, the patients photograph is also on the treatment computer screen for
verification. In contrast, retrospective risk identification strategies detect errors after they occur.
An example is the Radiation Oncology Quality Reporting System (ROQRS).4 ROQRS is an
online real-time system through which employees can voluntarily report safety issues.4 Personnel
can identify themselves or remain anonymous. Once a report is submitted, an email is instantly
sent to alert key personnel allowing them to begin the process of resolving the matter. This may
include immediate action for urgent issues or discussions and further evaluation of the treatment
plan or dosimetric data.4 Review may lead to a change in policies or protocol, which will
positively affect radiation safety for the patient. ROQRS is modeled after the national Radiation
Oncology Incident Learning System (RO-ILS), which links most facilities across the United
States with retrospective risk identification strategies.4
Facilities follow radiation safety regulations set by the Nuclear Regulatory Commission
(NRC).5 These federal regulations provide a level of assurance of public health and safety
regarding ionizing radiation.6 One regulation addresses standards for protection, such as the As
Low As Reasonably Achievable (ALARA) principle. ALARA requires practitioners to deliver
the lowest dose of radiation possible.5 There are also radiation safety advisory agencies, which
provide additional guidelines. Furthermore, radiation oncology departments take steps to ensure
the safety of their patients and personnel. They conduct equipment quality assurance including
calibration tests.7 Clinics have patient-specific quality assurance, for example, medical physicists
approve all treatment plans.7 Departments perform personnel-specific quality assurance, such as
audits to make sure that staff are conducting verifications before patient treatments and radiation
oncology peer-review programs that focus on improving quality assurance.7
Although there have been some devastating errors in radiation therapy, their occurrence
is quite infrequent. Radiation oncology departments take precautions to mitigate such incidences.
Overall, the public should feel confident all professionals in the radiation oncology industry take
radiation safety seriously and their general safety should not be a major concern.

References
1. Bogdanicher W. Radiation offers new cures, and ways to do harm The New York Times.
January 23, 2010. http://www.nytimes.com/2010/01/24/health/24radiation.html?_r=0.
Accessed October 19, 2015.
2. 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. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3655402/.
3. Sundararaman S, Babbo, AE, Brown JA, Doss R. Improving patient safety in the radiation
oncology setting through crew resource management. Practical Radiation Oncology.
2014;4(4):e181-e188. http://libweb.uwlax.edu:2093/science/article/pii/S1879850013003275.
4. Rahn, DA, Kim GY, Mundt AJ, Pawlicki T. A real-time safety and quality reporting system:
assessment of clinical data and staff participation. International Journal of Radiation
Oncology, Biology, Physics. 2014;90(5)1202-1207. https//libweb.uwlax.edu:4172/#!/
content/playContent/1-s2.0-S0360301614040140?returnurl=null&referrer=null.
5. Khan FM, Gibbons JP. The Physics of Radiation Therapy. 5th ed. Philadelphia, PA: Lippincott,
Williams & Wilkins; 2014.
6. Abing, C. Radiation Safety: Radiation Effect on Humans. [SoftChalk]. La Crosse, WI: UW-L
Medical Dosimetry Program; 2015.
7. Radiation therapy safety. Northwestern Memorial Hospital Web Site. http://www.nmh.org/nm/
quality-radiation-safety. Updated December 2, 2011. Accessed October 19, 2015.