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Yasmin Ahmed
DOS 516: Radiation Safety in Radiation Oncology
Patient Safety in Radiation Oncology
A 2010 New York Times article

describes cases in where radiation delivery went horribly
wrong, resulting in overdosing of radiation to patients. This was part of a series of articles
printed in 2010 entitled, The Radiation Boom. The first story describes the case of Mr. Jerome-
Parks who was being treated for tongue cancer at St. Vincents Hospital in New York City. For
three straight days, an undetected error caused the linear accelerator to overdose his brain stem
and neck. This overdose left Mr. Jerome-Parks with severe loss of vision, deafness, inability to
swallow, burning, tooth loss, ulcers in the mouth/throat, and pain. Eventually, he was also unable
to breathe and he eventually passed away after the initial error.
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Immediately following the incident at St. Vincents Hospital in Manhattan, New York
State health officials issued a warning to hospitals stating they should be very diligent with care
related to the use of linear accelerators, since they are able to produce very high levels of
radiation. Despite this, on the day this warning was issued, another New York City hospital was
involved in an incident resulting in a fatal overdose. Ms. Alexandra Jn-Charles was being treated
for breast cancer at the State University of New York Downstate Medical Center in Brooklyn,
New York. She received three times the prescribed dose on 27 fractions of treatment due to a
missing wedge on the linear accelerator. This overdose left a massive wound in her chest and
Ms. Jn-Charles died shortly thereafter.

The article

also claims that many incidents are often
hidden from the public. A hospital in Philadelphia, Pennsylvania delivered an incorrect dose to
over 90 prostate patients and then kept the matter hidden. Also, in 2005 a hospital in Florida
revealed that 77 patients with brain cancer were overdosed by 50% for about a year because the
linear accelerator was not programmed correctly.
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This article was definitely a wake-up call and good reminder to all radiation oncology
staff to be diligent in their workflow. However, the article and countless others like them may
have also created a deep fear in many people in regards to radiation therapy. In response to this
article, the American Association of Physicists in Medicine (AAPM) quickly put together a
meeting that resulted in a paper with recommendations for radiation safety in radiation therapy.
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The meeting had over 400 attendees that included physicians, dosimetrists, physicists,
administrators, manufacturers, and many others involved in the radiation oncology field. The
AAPM paper discusses what factors may lead to errors occurring and how they can be reduced.
A few recommendations were that the therapist workstations should be neat and organized,
others should not distract therapists while they are treating, departments should have enough
staff present, early warning procedures should be improved, equipment manufacturers should
resolve any concerns raised by oncology staff, and the planning and treating consoles should
have less windows/monitors, etc.
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Many departments also enhance patient safety and quality through daily chart rounds,
second checks, computerized equipment, and in vivo dosimetry. During chart rounds, many of
the staff involved in the treatment are present, including the radiation oncologist. At this time,
the treatment plan of each patient is reviewed for any errors or improvements that may be made.
This includes review of the patient volume to be treated and making sure the prescription has
been entered correctly in accordance with physician notes. Even with this in place however, most
errors occur at the treatment machine. The therapist is the final person to check that all factors
are correct. There should always be at least two therapists at the console to verify information
and perform a timeout before treating. Physicists must also perform all pre-treatment
verification and make sure all quality assurance procedures are complete.
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Most departments also
follow a recommendation by the American College of Radiology (ACR) that suggests verifying
treatment parameters through additional checks that should occur sometime within the first week
of treatment. Many facilities also employ computerized record and verify systems that aid in
reducing errors by preventing the machine from delivering radiation if there is a mismatch of
information. Finally, another check to verify dose received by the patient is through in vivo
dosimetry. This involves the use of a device that tells the staff approximately how much dose
was received by the patient. If there is a large deviation, that will warrant further investigation by
the medical physicist.
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The public must be reminded that radiation therapy can be a life saving treatment option
for many patients. As with any medical procedure, the benefits must outweigh the potential risks.
With the advancements in technology available today, patients are benefitting from the high
quality, accurate treatments that radiation oncology departments are able to provide.
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About
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40%-60% of all cancer patients are treated with radiation therapy. However, due to the high-risk
nature of radiation delivery, there are many steps undertaken before the patient is treated to
ensure safety. The oncologist, dosimetrist, physicist, therapist, and other professionals are
responsible for working together to provide the best possible care to each patient. Due to this
cohesive working environment, errors in radiation therapy are a rare occurrence. If errors do
occur, they are usually caught early and result in little to no harm to patients. In fact, significant
errors are so minimal that most radiation oncology professionals will not encounter one in their
whole career. This is due to the fact that delivery of radiation therapy is strictly regulated at both
state and federal levels.
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When a patient arrives to the radiation oncology department, they should be reminded by
staff of all steps the department takes to ensure their safety. This includes chart rounds, various
checks done by the physicist, etc. While we cannot guarantee that an error will not occur, we can
do our best to educate the patient on safety procedures performed to ease any fears or pre-
conceived notions they may have. In turn, the patient will feel more confident in trusting the
competency of the staff as well as the department as a whole. We must also stress that we are
here for the patient and they should not be afraid to ask questions or raise any concerns. As
Marie Curie
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once said, Nothing in life is to be feared, it is only to be understood. Now is the
time to understand more, so that we may fear less.








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References
1. Bogdanich W. The Radiation Boom: Radiation Offers New Cures, and Ways to Do
Harm. NY Times website.
http://www.nytimes.com/2010/01/24/health/24radiation.html?pagewanted=all&_r=0.
Published January 23, 2010. Accessed October 15, 2014.
2. Hendee WR, Herman MG. Improving Patient Safety in Radiation Oncology. Med Phys
[online]. 2011;38(1):78-82. Available at:
http://scitation.aip.org/content/aapm/journal/medphys/38/1/10.1118/1.3522875. Accessed
October 15, 2014.
3. Marks LB, Adams RD, Pawlicki T, et al. Enhancing the role of case-oriented peer review
to improve quality and safety in radiation oncology: Executive summary. Practical
Radiation Oncology [online]. 2013;3:149-156. Available at:
http://download.journals.elsevierhealth.com/pdfs/journals/1879-
8500/PIIS187985001200207X.pdf. Accessed October 16, 2014.
4. Errors in Radiation Therapy. Pennsylvania Patient Safety Advisory [online]. 2009;
6(3):87-92. Available at:
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Sep6%283%29/Pa
ges/87.aspx. Accessed October 15, 2014.
5. Marie Curie Quotes. Brainy Quote website.
http://www.brainyquote.com/quotes/authors/m/marie_curie.html. Accessed October 15,
2014.