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Brittany Bird
DOS 516: Radiation Safety
October 26, 2016
Implementation of Safety Protocols in Radiation Therapy
Approximately 1.6 million people in the United States were diagnosed with cancer in
2015 and two-thirds likely underwent radiation therapy.1 Radiation administration is considered
a high-risk procedure due to the use of high voltage and several patients fear the risk of being
overdosed. As more cancer-related diagnoses and recurrences arise, patients are becoming more
aware and cautious of the radiation therapy procedures and the risks that go along with receiving
the treatment. As professionals in this field, we must assure patients that radiation can be
administered in a proper manner that is both safe and effective by maintaining continuing
education requirements, performing quality assurance checks, using sophisticated and precise
techniques, and continuous advancements in technology.
The process of radiation therapy involves multiple people and contains complex steps,
which could open opportunities for error and lead to overdosing or other harmful mistakes.
There have been a few catastrophic incidences that have been publicized, such as the case in
New York where a computer error went undetected and the patients brainstem was irradiated at
large doses.2 In another case, a female patient undergoing breast cancer treatment was overdosed
by three times her prescription due to a missing filter in the head of the linear accelerator.2 While
errors in radiation therapy do occur, the mistakes have been addressed and learning processes
have been developed in order to detect and prevent these types of errors.
In the field of Radiation Oncology, a team of people comprised of Radiation Therapists,
Medical Physicists, Medical Dosimetrists, and Radiation Oncologists work in conjunction to
determine the correct treatment plan that is suited for the patient. All of these individuals must
hold a specific certification in order to be employed and handle the delivery of radiation. For
example, Radiation Therapists must pass a national board examination that is administered by
the American Registry of Radiation Therapy (ARRT). Every two years, a minimum of 24
continuing education credits must be met by either attending annual conferences or by
completing tests after reading publications. As of February 2012, there are still 15 states where
Radiation Therapists are not regulated.1 A proposed modification for this to create a national
standard is the Consistency, Accuracy, Responsibility, and Excellence in Medical Imaging and

Radiation Therapy (CARE) bill. This bill requires that the individuals who perform these
procedures have graduated from a recognized program, passed the national board examination,
and maintained competency through continuing education.3 Each individual should be
knowledgeable and held responsible for their position in the department. Radiation Therapists
are accountable for double-checking parameters, verifying patient set-ups, and monitoring the
patient during their treatment to ensure accurate delivery while eliminating any errors.
Quality assurance checks must be performed regularly on a linear accelerator by a
qualified Medical Physicist to ensure reliability and proper calibration of the machine. Several
organizations such as The World Health Organization (WHO), the International Atomic Energy
Agency (IAEA), and the International Commission on Radiological Protection (ICRP) have
established quality assurance guidelines to reduce the likelihood of an accident from occurring.1
The guidelines in place advise that mechanical tolerances are within 1-2mm and dosimetric
tolerances are within 2%.1 The Radiation Therapist is responsible for morning QA and will alert
the Physicist if anything is out of tolerance. Once a treatment plan is established, double-checks
are made between the Physicist and Dosimetrist. At the machine prior to the patients first
treatment, the plan is verified by ensuring that the independent check was performed, and that
the prescription and plan parameters match in the Record & Verify System. Although radiation
therapy is a multi-step process and several different individuals are involved, double-checks and
quality assurance tasks help to detect if there are any errors before the initial treatment so that
they can be adjusted.
With the rapid advancements in technology, the planning and delivery of radiation
treatments has vastly improved. There is less room for error through the use of On-Board
imaging, three-dimensional computed tomography (3DCT), multi-leaf collimation (MLC),
intensity modulated radiation therapy (IMRT), and dynamic wedges. Over the course of time,
the introduction of these new techniques has allowed for verification of the correct site for
treatment before beaming on and can create tighter margins to spare more normal issue. In-vivo
dosimetry devices are also available to monitor the dose that the patient will be receiving. The
use of these new technologies may require additional steps or double-check procedures, however
they are more beneficial in regards to the patients safety.
Errors can be minimized by following proper guidelines, utilizing certified professionals,
performing quality assurance checks, and using the latest technology, however, nothing is ever

perfect. Mistakes will occur even when procedures are in place to ensure patient safety. The
Nuclear Regulatory Commission (NRC) has estimated that approximately 60% of radiotherapy
incidents are due to human error.1 Currently, if an employee makes a mistake, there is no
voluntary reporting system in place to account for the number of overdosing events. The
American Association of Physicists in Medicine (AAPM) and the American Society for
Therapeutic Radiology and Oncology (ASTRO) have recognized this fault and are working
towards a solution to develop a national reporting system.4 It is imperative that every
professional work in their scope of practice and recognize when a mistake is made.
Administrators at institutions should promote an environment where reporting an error is the
right thing to do. There are still many improvements and procedures that need to be instilled
when it comes to reporting errors. Most importantly, patients need to be aware that the chances
of overdosing incidences occurring are rare, and that processes are being implemented to
improve and detect these types of errors.

1. Odle, Teresa G and Rosier, Natasha. Radiation Therapy Safety: The Critical Role of the
Radiation Therapist. ASRT White Paper. Accessed on
October 25, 2016.
2. Bogdanich W. Radiation offers new cures, and ways to do harm. Health. January 2, 2016. Accessed October 26, 2016.
3. ASRT. Ensuring Safe, Accurate Medical Radiation Procedures.
Accessed October 25, 2016.
4. Terezakis SA, Pronovost P, Harris K, DeWeese T, Ford E. Safety strategies in an academic
radiation oncology department and recommendations for action. 37(7). Accessed October 26, 2016.