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Ian Zoller
DOS 516 Fundamentals of Radiation Safety
October 24, 2016
Safety in Radiation Oncology
In the public eye, exposure to radiation is a topic that is very intimidating. Recent stories
reported in the New York Times of the horror of two patients deaths in 2010 spark feelings of
intense fear. In addition, a world history of atomic bombs and nuclear reactor disasters cause
people to associate radiation with danger and severe health effects. Radiation exposure is a
subject to be cautious of, but it is a necessary tool used in medicine to help diagnose and cure
disease. Mistakes can be made in the field of radiation therapy; however these errors occur few
and far between. An increased focus on quality assurance procedures for both mechanical and
human factors used in radiation treatments helps to limit these mistakes as much as possible.
As with every field in medicine, accidents are able to take place. However in contrast to
public perception, radiation accidents are a relatively uncommon occurrence and the majority of
these mistakes carry no significant changes in prescribed patient dose. In a study completed by
Hunt, Pastrana, Amols, et al,1 the authors reviewed the number of medical events that occurred at
their facility, Memorial Sloan-Kettering Cancer Center, from January of 2001 to December of
2010. The purpose of the study was to review the frequency of medical events in a time period
long enough to incorporate significant technological change. Over the course of 10 years, only
284 events had been recorded out of 597,000 total treatments. This corresponds to an event rate
of 0.93% per course of treatment which is consistent with results recorded by other large
radiation oncology centers. Furthermore, errors recorded during this time period were not
significant enough to change the tumor dose by more than 10%.1 To put into perspective the
frequency of medical events in radiation treatments, a malpractice study completed by Johns
Hopkins in 2012 reported that over 4,000 major mistakes are made in surgery in the United
States each year.2 That equates to over 40,000 mistakes nationwide in the same 10 year period.
The authors continued to break down the data according to which part of the treatment
process the mistake occurred: simulation, treatment planning, data transfer, or treatment delivery.
Most of the errors that had occurred were associated with parts of the process involving a heavy
amount of human intervention. The authors concluded that treatments involving more of the

human element carried an event risk four times higher than those relying heavily on computeraided design and delivery.1 As the time period progressed and more technology was introduced,
the authors found the frequency of medical events decreased over the course of the study. The
authors associated this downward trend with technological advancement such as improved
record and verify systems and the use of multileaf collimation.1
As was mentioned previously, accidents in radiation oncology occur very seldom. Linear
accelerators along with equipment used in brachytherapy procedures and patient treatment plans
go through rigorous quality assurance checks before a patient is able to be treated. Linear
accelerators undergo daily, monthly, and yearly tests or checks in accordance with the American
Association of Physicists in Medicines (AAPM) TG-142 that test parameters such as beam
output, safety mechanisms, accuracy of imaging, laser localization, and patient monitoring
devices just to name a few. The purpose of this quality assurance is to be sure that the linear
accelerator is delivering dose to a target volume within 5% of what is prescribed by the radiation
oncologist.3
In addition to quality assurance of the linear accelerator, many treatment facilities require
second checks of the patients treatment plan before the first treatment is administered. The plan
needs to be approved by the radiation oncologist and oftentimes goes through a second check by
staff members such as another dosimetrist, physicist, and radiation therapist to make sure that the
fractionation of the dose and calculated monitor units are correct against the prescription.
As mentioned in the study by Hunt et al,1 many of the errors in radiation therapy today
are due to human error. In order to increase the safety of treatments, many facilities are
developing programs to help reduce this factor. For example, the authors Chera, Jackson,
Mazur, et al4 suggest using a peer review process before a patients treatment plan begins where
all members of the radiation oncology department are included. This process is used in order to
design the best plan possible and to get as many available inputs in order to help reduce error and
also to help decrease the number of patients needing replanned. Another suggestion made in the
article is the implementation of weekly patient chart checks.4 The purpose of this practice is to
review what has been done for the patient from week to week and to catch errors before the
problem escalates or to make sure a patients chart is complete.

In relationship to every person in the world or in the United States, the part of the
population that receives the amount of radiation discussed above is the minority. As for the
general public, the health effect that is of most concern is the development of cancer from
radiation exposure. Most people do not realize that the population is exposed to radiation
constantly from sources such as the earth, atmosphere, medical imaging, radon gas, even foods
such as bananas.5 Most of the information society has about the health effects associated with
ionizing radiation has come from long term studies of atomic bomb survivors or people affected
by disasters such as Chernobyl. In these large exposures, radiation is seen to increase the amount
of cancer in the population, however, a determination of the risk associated with very small
exposures such as what the general public receives is unable to be determined. Most
organizations on radiation safety assume a linear no threshold model of risk, meaning that any
radiation exposure has the potential to cause cancer and that chance increases with increasing
exposure. This model is thought to be a conservative point of view to err on the side of caution.
To put things into perspective, Thomas and Symonds state that exposure to radiation from the
atomic bomb or as a cleanup worker after Chernobyl is less damaging to a persons health than
obesity or passive smoking.5
In the media, exposure to radiation has been played out to the extent that there is a major
concern associated with any amount of radiation exposure, however small. In reality, the use of
radiation is a necessary means to diagnose and cure disease. As with all fields in medicine,
accidents do occur in radiation therapy but the frequency of these events is very low. Quality
assurance procedures used for equipment and staff are effective measures in limiting these events
and making radiation therapy a safe treatment option.

References
1. Hunt MA, Pastrana G, Amols HI, et al. The impact of new technologies on radiation
oncology events and trends in the past decade: an institutional experience. Int J Radiation
Oncol Biol Phys. 2012;84(4): 925-931.
2. Makary MA, Mehtsun WT, Ibrahim AM, et al. Johns Hopkins malpractice study: surgical
never events occur at least 4,000 times per year. Johns Hopkins Medicine Web site.
http://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_malpractice_study
_surgical_never_events_occur_at_least_4000_times_per_year. December 19, 2012.
Accessed October 26, 2016.
3. Klein EE, Hanley J, Bayouth J, et al. Task group 142 report: quality assurance of medical
accelerators. Med. Phys.2009;36(9): 4197-4212.
4. Chera BS, Jackson M, Mazur LM, et al. Improving quality of patient care by improving
daily practice in radiation oncology. Semin Radiat Oncol. 2012;22: 77-85.
5. Thomas GA, Symonds P. Radiation exposure and health effects is it time to reassess the
real consequences? Clinical Oncology. 2016;28: 231-236.