Accident prevention in day-to-day clinical radiation therapy practice

Abstract

Nearly 50-60% of cancer patients will undergo radiotherapy at some point in their treatment. Around 85% of the world's population live in developing countries served by approximately 30% of the world's radiotherapy facilities. It has been suggested that 1 megavoltage unit is required for every 500 new treatment courses per year, while others estimate that 1 megavoltage unit is needed for every 300 new treatments. However, these numbers do not necessarily take into account the development of new technologies and treatment modalities, which are more time- and resource-intensive. The International Commission on Radiological Protection has emphasised that 'purchasing new equipment without a concomitant effort on education and training and on a programme of quality assurance is dangerous', and 'the decision to implement a new technology for radiation therapy should be based on a thorough evaluation of the expected benefits, rather than being driven by the technology itself'. It is estimated that the rate of serious mistakes could be as high as 0.2%, which is several orders of magnitude higher than the rate reported for commercial aviation. So, how safe is safe? It can be stated that the development of a culture of safety is critical and requires efforts in education and training, which could prove difficult in overloaded departments.

Reported Radiation Overexposure Accidents Worldwide, 1980-2013: A Systematic Review

“…While some errors such as errors in treatment site or dose administered, affect a single patient, other errors such as software issue, calibration or treatment programming errors, can affect multiple patients before the issue comes to light. Error reporting systems such as ROSIS allow learning from the past through knowledge of near-misses, incidents or accidents and constitute essential prevention tools [ 311 ].…”

“…As the use of radiation therapy is expected to grow even more in the future, it is crucial to ensure high quality assurance standards in order to avoid the multiple possible errors in the course of treatment and thus optimize all benefits of radiation therapy [ 309 – 311 ].…”

Radiation Oncology Quality and Safety Considerations in Low-Resource Settings: A Medical Physics Perspective

“…New technologies provide new risks of treatment errors as indicated by the 2009 ICRP report 8 , the articles from the New York Times 11 and multiple other reports [12][13][14][15] .…”

Factors associated with event reporting in the pediatric radiation oncology population using an electronic incident reporting system

“…Certain aspects of general radiation oncology practice, including rapid introduction of new technology, are recognized to potentially increase the risk of patient harm. 1 Efforts to introduce and promote safety culture are aimed at reducing the secrecy that may surround incidents and near misses that could generate learning, 2,3 as well as improving communication initiatives that may assist with identification of patient and other factors that increase risk of incurring harm. 4 Electronic reporting systems have been identified as an optimal method of openly reporting near misses, incidents, and errors.…”