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An Analysis of Radiation Therapy Medical Events in New York State: The Role of the State Radiation Programs in Patient Safety

Krishnamoorthy, Janaki; Salame-Alfie, Adela; O’Connell, John*

doi: 10.1097/HP.0000000000000091
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From 2001 through 2009, the New York State Department of Health (NYSDOH) has documented 244 reports of radiation therapy events, of which 228 have resulted from the delivery of radiation beam therapy using linear accelerators (LINACs). Historically, radiation therapy events involving LINACs have not been uniformly reported across the country because LINACs are regulated by state radiation control programs, and reporting requirements vary among states. The Nuclear Regulatory Commission’s Nuclear Material Events Database (NMED) only tracks events involving radioactive materials (RAM). Efforts to track medical events involving LINACs at a national level have begun only recently. This article highlights the importance of tracking and analyzing all medical radiation events in order to improve quality of care and patient safety. An analysis of a subset of the data collected by the NYSDOH from 2001–2009 is presented. This subset consists of only events arising from the use of LINACs in radiation therapy. There are very few publications on errors and error rates in the use of medical accelerators in radiation therapy. This analysis highlights the most common types of errors, causes and contributing factors, areas for improvement and actions taken to bring this information to the regulated community. An error rate of 0.07% per patient receiving radiation treatment is estimated using these data and the New York State Tumor Registry data for the same period. NY State Regulations governing the practice of Radiation Oncology have been revised recently to reflect the increased complexity in the delivery of therapeutic radiation. Collaboration and sharing of data such as those presented here, between federal, state and local regulators, professional organizations such as the Conference of Radiation Control Program Directors (CRCPD), American Society for Radiation Oncology (ASTRO), American Association of Physicists in Medicine (AAPM), American College of Radiology (ACR), American College of Radiation Oncology (ACRO), manufacturers of medical radiation equipment and software developers and the regulated community has begun and will contribute to improved quality of care and patient safety.

*New York State Department of Health, Bureau of Environmental Radiation Protection, Corning Tower, 12th Floor, Empire State Plaza, Albany, NY 12237.

The authors declare no conflict of interest.

Janaki Krishnamoorthy is an Associate Radiological Health Specialist at the Bureau of Environmental Radiation Protection in the NY State Department of Health. Krishnamoorthy earned a PhD in Nuclear Physics from Michigan State University and is certified by the American Board of Radiology in Therapeutic Radiological Physics. In the past, she has worked as a clinical medical physicist at Albany Medical Center Hospital in Albany, NY, and at several hospitals and centers in the Silicon Valley area in CA. She was the chair of the H34 Task Group of the CRCPD that developed a guidance document on Helical IMRT for state inspectors and was a member of the H38 Task Group that developed the voluntary reporting form of the CRCPD for diagnostic and therapy medical radiation events. Her email is jxk05@health.ny.gov.

(Manuscript accepted 2 January 2014)

© 2014 by the Health Physics Society