Despite a relatively low rate of therapeutic accidents, concern over safety in radiation oncology is growing, both among the public and within the specialty. As the field continues to evolve and become more technical, radiation oncologists may understand the frequency and causes of errors less and less, intensifying the need for greater quality assurance, argued the authors of a study published in the January-March edition of Practical Radiation Oncology.
Perhaps drawing the greatest attention to lapses in radiation oncology safety, The New York Times and the Red Journal published special pieces, followed two years later by FDA and Congressional hearings, telling of severe overexposure to radiation and other errors causing harm to patients. As the result, the authors sought to publish a review of the frequency of radiation therapy (RT) errors and offer opportunities and initiatives that might improve safety in the field.
The rate of error in radiation oncology is generally low, with the New York State Department of Health logging 230 events out of 373,000 RT patients between 2001 and 2009. According to the department, 37 of these were considered “serious events,” requiring the intervention of a physician, while making for a rate of approximately one serious event per 10,000 patients. “Therapist error” was cited as the cause in 84 percent of these cases.
Non-government studies, however, have concluded that approximately 1 percent of patients experience at least a minor and harmless deviation in their treatment courses, according to Lawrence B. Marks, MD, of the department of radiation oncology at the University of North Carolina in Chapel Hill, and colleagues. Still, the authors concluded that data on the frequency of errors is not well documented and therefore poses a challenge to improving quality.
Citing a number of possibilities for technical errors, as in segmentation, dosimetry and differences between portal and simulator films, the authors argued that as the points of failure and handoffs increase, physicians and therapists have become increasingly detached from one another and from patients, making errors easier to overlook.
Moreover, despite tremendous advantages to improving technology, from therapeutic developments to EMRs, “these rapid changes may lead to stress and frustration and incomplete and erroneous documentation within the EMR, negatively affecting safety,” the authors argued. Prevailing reliance on technology “can also promote complacency (i.e., ‘it must be right, the computer said so’),” Marks and co-authors continued.
The authors insisted on the importance of quality assurance programs. Such initiatives must include strong communication and coordination between all stakeholders, including therapists, physicians and administrators. Marks commented on the University of North Carolina’s implementation of the Toyota Production System, wherein “[v]alue-added steps are identified, with wasteful steps and unnecessary stressors being eliminated, and a more streamlined, unambiguous, standardized process being defined.”
Marks and colleagues also enumerated the benefits to imbedded quality assurance functions, which have the ability to detect errors in patient identification and provide automated checks for target and dose parameters.
“The vast majority of patients treated with traditional and advanced technologies are treated safely as intended,” Marks and colleagues pointed out, while emphasizing that “ongoing changes in our clinical practice mandate continued vigilance to minimize the risks of error.”