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Low Daniel; Steinberg, Michael
Health Physics: November 2013
doi: 10.1097/HP.0b013e3182a1afdc
Papers: PDF Only


Radiation therapy is efficacious for the treatment of many cancers. The complexity of radiation therapy has increased steeply in the past 15 y. Technological developments have led to the automation of complex treatment planning and treatment delivery processes; the addition of in-room imaging systems, including cone-beam computed tomography; and the proposal to enable modification of the treatment plan based on the patient’s radiation response, a process termed adaptive radiation therapy. These technologies have provided the ability to increase radiation conformality and precision, improving the outcomes for many radiation therapy patients. This increase in treatment sophistication and complexity requires a commensurate enhancement of quality assurance procedure intricacy and erudition.

Reports of radiation overdoses and misadministrations have come to the attention of healthcare providers and have appeared in the press, highlighting some of the new risks generated by the emerging treatment paradigm. While radiation therapy is extremely safe, members of the public and radiation therapy professionals want to improve the safety record. There are many initiatives taking place in the radiation therapy professional associations to guide users in methods of improving the safety and quality of treatments. However, most of these either reemphasize or expand on the quality assurance paradigms that were developed prior to this new era of increased complexity.

The fact is that in order to improve the radiation therapy safety track record significantly, we will have to make significant changes in our training, workflow, and monitoring as well as address important cultural aspects of organizational change required to improve safety outcomes. To this end, the main stakeholders in radiation therapy, including physicians and medical physicists, professional organizations, the U.S. Food and Drug Administration, equipment manufacturers, software manufacturers, and patient advocates, will need to come together to articulate a systematic approach to improve safety in radiation therapy significantly. We propose that the components of the plan include: safety recording, monitoring, standardization, training, accreditation, and a robust organizational social infrastructure to implement the safety culture.

•Safety recording: An important ingredient in developing a long-term plan to increase radiation therapy safety is having data that tell us the types and causes of errors. Individual institutions are beginning to develop such reporting systems, but to date there are few, and those are without interconnectivity or data sharing. A broad, national, and required reporting system is recommended so that radiation therapy can gather data and plan safety improvements more accurately;

•Monitoring: The independent verification that prescribed safety procedures are optimal and correctly implemented. This includes internal and external peer review and in the future will also include automated computer-controlled monitoring systems;

•Standardization: The development and use of standardized treatment directives, policies, and procedures. Currently, most clinics develop their own procedures based on individual training, conventional wisdom, and biases of their providers. This results in wide variation in practice. However, absent treatment outcome differences due to the variation and the potential risk for increased mistakes in treatment delivery, there is little rationale to continue this wide-ranging approach. The safety benefit of standardization would be that sophisticated risk analyses could be implemented broadly;

•Training: This includes the concept of retraining using simulations that have built-in errors. Radiation therapy simulations could be used to train, retrain, and evaluate the effectiveness of staff in detecting and mitigating errors;

•Accreditation: Properly conducted accreditation can ensure minimum standards of care and safety in each facility; and

•Safety culture: Beyond implementation of the robust safety infrastructure, the social and cultural aspects of embracing attitudes of “no-fault” reporting in the context of the pursuit of zero mistakes completes the components of an effective approach to safety for radiation therapy.

The authors declare no conflicts of interest.

For correspondence contact: Daniel Low, UCLA Radiation Oncology, 200 Medical Plaza, Suite B265, Los Angeles, CA 90095, or email at

(Manuscript accepted 21 June 2013)

© 2013 by the Health Physics Society