Literature Review of two scholarly articles on the topic of Radiation Safety

Fiona Peck

DOS 516 Fundamentals of Radiation Safety

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Radiology has contributed significantly to the field of medicine, providing tremendous

hope and progress in cancer treatments. However, with all its benefits, danger also prevails.
Thus, radiation safety has been an essential topic of discussion since the inception of radiologic
imaging and treatment. In this paper, two different perspectives on the topic of radiation safety
were reviewed. The first article, "2010 ACR Presidential Address: Patient-Focused Radiology:
Taking Charge of Radiation Dose”, written by Carol M. Rumack, MD1, addresses radiation
overexposure concerns and how to reduce medical imaging doses, while the second article,
"Safety culture to improve accidental event reporting in radiotherapy" by Francesco Tramacere
et al. 2 provides empirical evidence on the benefits of reporting adverse events to reduce
occurrences. While both articles' perspectives may differ, they share common positions on what
is needed to improve radiation safety, notably continuous and proper education and training of
all staff responsible for administering radiation to patients.

The first article, "2010 ACR Presidential Address: Patient-Focused Radiology: Taking
Charge of Radiation Dose”, was written by Carol M. Rumack, MD1. Rumack was the 2010
president of the American College of Radiology (ACR), and her address was in response to a
growing public and media concern over radiation overexposure across the country. As the
President of the ACR, she addressed the concerns of radiation safety within her field of medical
radiologic imaging. Rumack strongly believed that safeguards and strategies must be
implemented to tackle these safety issues and lower the radiation dose during imaging
procedures. She provided a comprehensive list of nearly 30 recommendations she felt would
assist in this task, along with over a dozen examples of what ACR had already implemented that
have shown to be effective in reducing radiation exposure to patients. Rumack's leading
suggestions pertained to the concept of the standardization of institutions, programs, protocols,
and procedures through mandated registries (i.e., ACR National Radiology Data Registry, Dose
Index Registry, national CT dose registry), accreditation of imaging facilities and colleges, and
credentialing of radiologic personnel. She also emphasized proper education and training for all
radiologic personnel. Most salient to Rumack was to have all personnel administering radiation
trained in radiation risks and protection as she firmly believed it would help reduce the risks of
radiation overexposure. Among some of the ACR projects Rumack mentioned that have shown
remarkable results in reducing radiation dose in imaging were the Image Gently for pediatric
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patients and Image Wisely campaigns. According to ACR’s findings, the Image Gently
campaign managed to change personnel behavior within five years of its launch. It helped reduce
pediatric radiation dose parameters when pediatric patients received unnecessarily high radiation
doses during CT scans. Another successful initiative of ACR was their Appropriateness
Criteria® order entry program that assists physicians in ordering the most appropriate imaging
tests for their patients. Rumack stated that this program reduced the CT scan growth rate to 1%
from 12% five years prior. Kumack provided these examples to demonstrate her strong support
for the effectiveness of standardized programs and protocols.

The second article, "Safety culture to improve accidental event reporting in

radiotherapy," was written by Francesco Tramacere et al2. This article addressed the topic of
radiation safety by illustrating how acquired knowledge can modify practices. Tramacere et al.
conducted a seventeen-year-long study at a radiotherapy center that demonstrated how the
systematic reporting and analysis of adverse events could help reduce their occurrences. Before
conducting their study, Tramacere et al. emphasized the “no-blame or liability” policy to
encourage all staff to systematically report adverse events at the facility. Events were divided
into "incidences" and "near-misses.” Once an event was reported, a committee of members from
each professional branch met to discuss, evaluate, and determine what could be done to improve
their workflow procedures in an effort to reduce occurrences. By the end of the study in 2018,
Tramacere et al. collected 110 worksheets, representing an average of 6.1 adverse events per
year (less than 1% incident rate). Tramacere et al. categorized their study into three major time
frames to understand the dynamics of when these adverse events occurred most frequently. The
time frames were based on the workflow changes during the seventeen years. The first time
frame lasted eight years and was the department’s transition period (2001-2009). The second
time frame was the informatization period, which lasted three years (2010-2013). The third time
frame was the paperless period, which lasted four years (2014-2018). The time frame that
suffered the most events (42 total, including incidences and near-misses) was the informatization
period (2010-2013), where the department was transitioning to complete computerized
technology and from 3D conformal to VMAT planning practices. However, the time frame with
the most incidences was the transitional period (2001-2009), with a total of 13. The findings of
Tramacere et al. indicated that most events were due to insufficient supervision or rules, which
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required some procedures to be adjusted. The most significant finding was the change in staff
culture, where events were reported systematically without fearing repercussions. According to
Tramacere et al., this was a significant part of the success of utilizing event reporting as a tool to
help reduce adverse events. The team also mentioned other factors that could have contributed to
a reduction in events, including a better-trained staff, improved procedures, and increased
supervision. In conclusion, Tramacere et al. study confirmed that the use of systematic reporting
and analysis of events can assist not only in reducing the number of unintended events but also in
providing overall workflow benefits such as greater attention to details/problems, greater
collaboration between staff, better incorporation of step procedures, and reduction in staff
turnover.

These two articles were compelling in their approach to dealing with radiation safety.
Although it appeared that they came from two different perspectives, there were some common
grounds that they both mentioned as essential criteria to ensure the safety of patients while
administering radiation. Both Rumack and Tramacere et al. agreed that proper training and
expert skill acquisition of all staff in the field of radiology was paramount to reducing
unintended or unnecessary radiation dose. They also both mentioned how the change in culture
and behavior of the staff was the catalyst for improvement in how staff proceeded to operate.
Rumack stated that their Image Wisely campaign brought noticeable behavioral change to the
staff, as evidenced by their ability to reduce radiation dose to patients consistently. Tramacere et
al. mentioned how the culture change in the staff was the most significant finding from their
study, which indicated a willingness to improve their skills. Finally, both agreed on securing a
tracking system that would assist in avoiding radiation overexposure; however, they differ in
their approach. While Rumack proposed tracking patients' dose through a national registry to
alert facilities of any outliners proactively, Tramacere et al. focused on a reactive tracking system
of reporting and analyzing adverse events to develop a better workflow or procedure.

Although both articles had some common grounds on what they felt was fundamental in
reducing adverse events, such as proper education and training, they approached the matter of
radiation safety very differently. Rumack's recommendations were extensive, and many appeared
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very pragmatic, such as the Image Wisely campaign or the ACR Appropriateness Criteria®
program. Her efforts to mandate accreditation and credential all radiologic personnel are well
intended; however, according to the US Nuclear Regulatory Commission (NRC)3, most states
fall under the “agreement state” provision. Imposing mandates across the board would prove
challenging, especially on a federal level. As for Tramacere et al. study on adverse event
reporting, this system has proven effective in improving operational and workflow systems.
However, incorporating proactive measures, such as the Dose Index Register proposed by
Rumack, would provide the facility and its patients additional safety against overexposure.

References:

1. Rumack CM. 2010 ACR Presidential Address: Patient-Focused Radiology: Taking Charge of
Radiation Dose. J Am Coll Radiol. 2010;7(11):837–844.
https://doi.org/10.1016/j.jacr.2010.07.003

2. Tramacere F, Sardaro A, Arcangeli S, et al. Safety culture to improve accidental event

reporting in radiotherapy. J Radiol Prot. 2021;41(4):1317–1327.
https://doi.org/10.1088/1361-6498/ac0c01

3. United States Nuclear Regulatory Commission. Agreement States.

https://www.nrc.gov/agreement-states.html. Accessed December 4, 2023