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Nick Hopkins
DOS 516 – Fundamentals of Radiation Safety
Radiation Safety Paper

Radiation therapy is a highly specialized and complex process that is not immune to
errors. There have been several high profile reports of errors in radiation oncology resulting in
significant patient harm or death. This can be very troubling to the public because cancer is
prevalent in our lives. According to current statistics from the National Cancer Institute1 there is
a lifetime risk of around 38.5%, or about 1 in 2.6, of developing cancer in the United States.
Those who are not directly affected likely know someone who has been. In a study by Delaney et
al2 it was estimated that radiation therapy is indicated for 52% of cancer patients. This means
that for many of us, the decision whether or not to undergo radiation therapy is a pertinent one,
and safety concerns need to be addressed.
The availability of US error rates in the literature is limited, outside of institutional based
analyses.3 Though total number of errors are becoming more available through national Incident
Learning Systems (ILS), total number of patients, treatments, or fractions remains missing. An
international error rate of 1500 per million treatment courses of radiation therapy was identified
in a technical manual published by the World Health Organization (WHO).4 This data could be
illustrative for the US population, which was included in the analysis. The WHO compares this
rate to that of hospitalization for adverse drug reactions, which are 65,000 per million. This helps
put into perspective how incredibly low the risk of an error is during a course of radiation
Even though the risk of an error is low, the potential risk for harm when an error occurs is
still great. To this end, radiation oncology departments implement many layers of safety. A
significant number of departments are accredited by some formal body such as the American
Society for Radiation Oncology (ASTRO) Accreditation Program for Excellence (APEx) or the
American College of Radiology (ACR) accreditation programs. There are institutional layers,
such as licensure required continuing education credits in radiation safety or perennial Practice
Quality Improvement (PQI) projects. Radiation oncology equipment is also rigorously and
routinely checked during initial acceptance and commissioning, as well as annual, monthly, and
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daily quality assurance checks. Instruments integral to these checks are also required to be
calibrated by licensed facilities under reference conditions.
Additionally, patient specific safety practices involve a wide variety of steps.
Departments use simple processes such as asking for two identifiers to verify patient identity, as
well as complex record and verify software that ensures the actual equipment parameters match
the planned parameters. For treatment techniques with a greater mechanical complexity, such as
Intensity Modulated Radiation Therapy (IMRT) or higher fractional dose, such as Stereotactic
Body Radiation Therapy (SBRT), plans are delivered on a phantom, measured, and compared to
planned values before being delivered to the patient. All plans are also checked by the planner as
they are created, then by the physician, a physicist, and the radiation therapists prior to patient
Despite these layers, safety efforts are hindered by “the complexity of the disease, the
sophistication of the technologies employed, the intricacies of communication among members
of the treatment team and, probably foremost, the involvement of humans throughout the
treatment regimen.”5 In 2010, ASTRO and the American Association of Physicists in Medicine
(AAPM) started a safety initiative to address public safety concerns and guide the evaluation of
current safety practices.3 One of the direct results of this effort, and aided US congressional
action, is the creation of the Radiation Oncology Incident Learning System (RO-ILS).3,6 This
national database of reported errors helps individual participant institutions track and analyze
their errors as well as view anonymized national data for shared learning. The evolution of safety
within radiation oncology is also evidenced by the AAPM Task Group Report 100 (TG-100).7
This report provides a framework for assessing quality management (QM) and identifying high
risk process steps so that a proactive approach can be taken to prevent them, without the need for
retrospective analysis of errors that have occurred.
Some risk in radiation therapy is unavoidable, however there are many systems in place
to safeguard against those risks and to reduce their occurrence. There is a robust and integrated
safety culture within the profession with emphasis on support from the top down, equal
responsibility among all participants for patient safety, and cooperation.5 New ideas and ways of
assessing and addressing patient safety factors are also fostered by professional organizations.
For these reasons, radiation therapy remains among the safer medical procedures.
1. National Cancer Institute. Cancer of any site – cancer stat facts. Surveillance, Epidemiology,
and End Results Program. Accessed October
24, 2017.
2. Delaney G, Jacob S, Featherstone C, Barton M. The role of radiotherapy in cancer treatment:
Estimating optimal utilization from a review of evidence-based clinical guidelines. Cancer.
3. Marks L, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation oncology.
Practical Radiat Oncol. 2011;1(1):2-14
4. World Health Organization. Radiotherapy risk profile: Technical manual. Geneva,
Switzerland: WHO Publishing; 2008.
5. Hendee WR, Herman MG. Improving patient safety in radiation oncology. Practical Radiat
Oncol. 2011;1(1):16-21
6. Spraker MB, Fain R III, Gopan O, et al. Evaluation of near-miss and adverse events in
radiation oncology using a comprehensive causal factor taxonomy. Practical Radiat Oncol.
7. Huq MS, Fraass BA, Dunscombe PB, et al. The report of Task Group 100 of the AAPM:
Application of risk analysis methods to radiation therapy quality management. Med Phys.