Taylor Evans

October 1,2013
RadSci 3414
Reaction Paper
1. OConner Hartsell, S; Hartsell, WF. Minimizing Errors In Patient Positioning.
Radiol Technol. 1994; 3: 15-19.
Minimizing Errors In Patient Positioning
The ability to reproduce and treat the planned simulated field precisely is perhaps the
most important aspect of radiation therapy, yet it is also the most difficult(OConnor Hartsell,
Hartsell). In todays society, technological advances are more precise than ever with tumor
localization and target volumes compared to the late 1800s. Although, according to Siobbhan
OConnor Hartsell and William F. Hartsell, radiation therapist are not taking into account for
potential problems during set up that might seem minuscule but could make considerable
differences in treatment outcome. The potential problems OConnor Hartsell and Hartsell
address within their article are the following: failure to use adequate external marks, loss of these
marks, changes in position of body parts outside the treatment area, lack of adequate
immobilization, patient movement, changes in the patients body contour caused by weight
fluctuations or edema, and failure to account for respiratory or cardiac motion. The three most
important aspects they referenced where simulating patients in a reproducible, comfortable
position, clean skin marks/ with photos being taken, and repetitive daily treatment (OConnor
Hartsell, Hartsell).
During the treatment planning process, the patient should be stimulated in a
reproducible, comfortable position(OConnor Hartsell, Harsell). I agree very strongly with this
concept because if the patient is tense/stressed out during stimulation, then the marks placed on
the patient that day, will be off once the patient comes back for their treatment. I find it

imperative to talk the patient through what is going to be happening during stimulation in
laymens terms. I think the patient needs to understand that the therapists are not treating them
that day, only prepping. Also, explaining to the patient how important it is for them to relax but
also ask them how we can help them feel more comfortable, as well. A good way to help the
patient feel comfortable would be to ask if they would like a towel under their arm to let them
know they are in some control of what is happening. A way to improve treatment dose could be
getting the patient positioned during simulation by putting ink marks, not tattoos, on them and
having the patient come back for treatment on their first day and then tattooing them after their
ports have been taken. This would eliminate room for errors in remembering the patients shift if
the physician were to move the isocenter .5cm every time for treatment, just because their ports
were different, from when they were simulated. I feel this method would be more consistent for
the continuance of the patients treatment and easier for accurate set up each day. Immobilization
and comfort are crucial aspects for the patients treatment outcome, which is why it needs to be
carried out from the first day of simulation until the last day of their treatment.
At least seven marks are required to adequately define the volume(OConnor Hartsell,
Hartsell). I find a few problems amiss with a seven-point set up. One problem I see would be
concerning the chest region. I think a three-point set up would be more beneficial considering
how breast tissue, especially for bigger busted woman, has more ability to move therefore
causing inadequate dose being delivered. I think a three point system through out all the hospitals
would benefit much more rather than just using multiple techniques or marks to set up breast
patients. This technique is being tested throughout Riverside and Grant by using the supraclav as
a mono-isocentric reference instead of having two isocenters. I believe this system would benefit
the therapist by limiting the times having to go in and out of the treatment room, to move the

patient superior and inferior to align with a second isocenter. Also, by making the treatment
faster but also accurate because there will be no need to readjust. I think it will also benefit the
patient by making the simulation set up quicker and also their treatment time will be faster.
I can not say I agree with the statement using multiple points to define the treatment
volume can reduce problems (OConnor Hartsell, Hartsell) because I think therapist can be just
as accurate or even more precise with a three point set up that has two lateral marks/tattoos and
one isocenter that is stable and can not move. Immobilization is key in treatment set up but so are
the marks and tattoos. I do agree that therapist need to be taking photos of the accurate set up in
simulation to better increase the correct treatment set up on allowing the correct treatment
volume to be treated. If not, error will be introduced and the patient might need to be simulated
again.
The repetitive daily treatment is the component of treatment that is most prone to error..
(OConnor Hartsell, Hartsell). I highly agree with this statement as well, because patients are
not being immobilized efficiently each day they are being treated. Immobilization could range
from placing the arm all the way into the arm cradle/using a knee sponge/ or seating all the way
in the Alpha Cradle. I think therapists need to be aware of the patients position before beginning
treatment, which consists of rechecking the set up a few times if necessary.
Reproducibility is another component of treatment, which can include markings on the
patients skin. I think markings on the patients skin, using sharpie or ink pens, play a big role in
accuracy. Inaccuracies in drawing over the lines everyday with different size markers or another
therapist going over the markings constantly could possibly push the isocentric set up over a
little each day. Although it might be a small change it could cause the wrong volume of tissue to
be treated. Redrawing lines can also cause inaccuracies of reproducing the correct set up. As

therapists continue to draw over the same marks each day the thicker they can become causing
error within the set up. These marks are now likely to become closer to the wrong volume of
treatment being administered throughout the patients treatment. In order to improve these
markings, I think therapist should use tattoos because they are smaller and cannot move to better
insure accuracy.
In conclusion, simulating the patient in a reproducible, comfortable position, clean skin
marks/ photos being taken, and repetitive daily treatment are vitally important in treatment
volume, especially giving the correct amount of dosage to the wrong volume. I think therapist
need to take their time with set up and make sure everything is where it should be. Careful and
accurate treatment allows the best chance of a good outcome(OConnor Hartsell, Hartsell),
which I think every patient deserves.