Report: Time for national radiation oncology safety standards

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Although overwhelmingly safe, radiation oncology’s error record does not stack up to similarly complex industries like aviation and nuclear power. In fact, national coordination of reporting and preventing radiation oncology errors has made little progress, while the field has become increasingly complex, according to a July article published in The Joint Commission Journal on Quality and Patient Safety.

Nearly 50 percent of cancer patients undergo radiotherapy, with figures estimating that roughly one in 500 experiences an error, most of which are likely to be clinically insignificant, according to one study. Yet, “these error rates do not compare favorably to other ultrasafe industries such as commercial aviation or nuclear power generation, nor do they compare well with other areas of medicine such as modern anesthesiology and blood transfusion,” stated Stephanie A. Terezakis, MD, and co-authors from the Johns Hopkins School of Medicine in Baltimore.

“Although the vast majority of these treatments are safe and effective, when treatment errors do occur they can have serious consequences,” Terezakis and colleagues wrote. Their report comes in stride with a July white paper released by the American Society for Radiation Oncology (ASTRO), which critiqued the lack of structured quality and safety steps employed during intensity-modulated radiation therapy (IMRT),

Terezakis et al pointed to the airline industry as the gold standard, applauding the industry’s institution of a national error-reporting system and public-private partnerships seeking to “design risks out of airplanes.” The result has been a halving of the fatality rate for flyers, down to 0.022 per 100,000 departures.

Despite marginal efforts to the contrary, Terezakis and colleagues held that “little tangible progress toward a national event-reporting system [in radiation oncology] has yet been made.”

Of equal urgency, the authors offered, is the development of consensus definitions of errors and near misses. They contended that with growing dependence on computer-based radiotherapy systems and the increasing complexity of treatments, double-checks have decreased.

In their own internal safety assessment, Johns Hopkins researchers identified 270 steps to each radiotherapy treatment and 159 possible failure modes. After implementing an event reporting log, the researchers further discovered that nearly half of all errors fell outside of the 159 potential errors for which they had planned.

Risk reduction requires risk assessment—and prioritization. For individual hospitals and clinics, the authors recommended the establishment of committees that consist of members covering all points of the clinical radiotherapy team, who could then vote to quantify and prioritize risks.

Top-ranked errors warrant the speediest interventions, which should be chosen based on feasibility, effectiveness and consensus. Although resource-intensive, individual clinics should strive to establish error-reporting systems, which can help identify and prioritize hazards, but these reports are not a panacea, according to the authors.

Similarly, Terezakis and colleagues called for a safety reporting system on the national level as well, both to identify systematic challenges and provide baselines for practices.

The authors also urged heightened cooperation between manufacturers, clinical staff and quality assurance and human factors experts. “There are strong economic incentives for industry to get these [radiotherapy] devices to market, but human factors principles cannot be overlooked.”

Finally, the report borrowed a quality assurance model employed by the American College of Radiology (ACR) and other specialty organizations: peer-review. By way of peer-review, radiation oncology clinics could anonymously assess one another while also sharing best practices. Such a scheme could also help smaller clinics share resources, given the resource-intensive nature of internal quality control for the complex medical therapy.

Reflecting on recent advancements in radiation oncology, the authors concluded, “The ‘basic science’ of radiation treatment has received considerable support and attention in developing novel therapies to benefit patients. The time has come to apply the same focus and resources to ensuring that patients safely receive the maximal benefits possible.”