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Systematic review

An international review of patient safety measures in radiotherapy practice

Jesmin Shafiq a,*, Michael Barton a, Douglas Noble b, Claire Lemer b, Liam J. Donaldson b

a The Collaboration for Cancer Outcomes Research and Evaluation, University of New South Wales, Sydney, Australiab WHO World Alliance for Patient Safety, Avenue Appia 20, Geneva, Switzerland

a r t i c l e i n f o

Article history:

Received 8 October 2008

Received in revised form 4 March 2009Accepted 4 March 2009

Available online 22 April 2009

Keywords:

Patient safety

Radiation protection

Radiotherapy accident/s

Radiotherapy error/s

Radiotherapy incident/s

Quality assurance

a b s t r a c t

Errors from radiotherapy machine or software malfunction usually are well documented as they affect

hundreds of patients, whereas random errors affecting individual patients are more difficult to be discov-

ered and prevented. Although major clinical radiotherapy incidents have been reported, many more have

remained unrecognised or have not been reported. The literature in this field is limited as it is mostly

published as a result of investigation of major errors. We present a review of radiotherapy incidents inter-

nationally with the aim of identifying the domains where most errors occur through extensive review

and synthesis of published reports, unpublished Grey literature and departmental incident data. Our

review of radiotherapy-related events in the last three decades (19762007) identified more than seven

thousand (N= 7741) incidents and near misses. Three thousand one hundred and twenty-five incidents

reported patient harm of variable intensity ranging from underdose increasing the risk of recurrence,

to overdose causing toxicity, and even death for 1% (N= 38); 4616 events were near misses with no rec-

ognisable patient harm. Based on our review, a radiotherapy risk profile has been published by the WHO

World Alliance for Patient Safety that highlights the role of communication, training and strict adherence

to guidelines/protocols in improving the safety of radiotherapy process.

2009 World Health Organization. Published by Elsevier Ireland Ltd. All rights reserved. Radiotherapy

and Oncology 92 (2009) 1521

Introduction

Radiotherapy treatment

Radiotherapy is one of the major treatment options in cancer

management. According to the best available evidence[2], 52% of

patients should receive radiotherapy at least once during the treat-

ment of their cancer. Together with other modalities such as sur-

gery and chemotherapy radiotherapy plays an important role in

the treatment of 40% of those patients who are cured of their can-

cer[3]. Radiotherapy is also a highly effective treatment option for

palliation and symptom control in cases of advanced or recurrent

cancer. The process of radiotherapy is complex and involves under-standing of the principles of medical physics, radiobiology, radia-

tion safety, dosimetry, radiotherapy planning, simulation and

interaction of radiation therapy with other treatment modalities.

The main health professionals involved in the delivery of radiation

treatment are the radiation oncologists (RO), radiation therapists

(RT) and medical physicists (MP). Each of these disciplines works

through an integrated process to plan and deliver radiotherapy to

patients. The sequential stages of the radiotherapy process of care

(Fig. 1) were agreed by the Expert Committee of WHO World Alli-

ance for Patient Safety[1].

Errors in radiotherapy treatment

Accidental exposures to radiotherapy may result from an acci-

dent with a radiation source or from an event or a sequence of

events including equipment failures and operating errors[4]. Elab-

orate quality assurance (QA) protocols have been issued by a num-

ber of international and regional organisations in order to reduce

the likelihood of accidents and errors occurring, and to increase

the probability so that the errors will be recognized and rectifiedquickly if they do occur [513]. Still the potential for the errors

in radiotherapy is high as it involves highly technical measure-

ments and calculations of different radiation doses to many differ-

ent parts of the body. Treatment is delivered in multiple daily

doses and patient set-up must be accurate and reproducible. Mod-

ern radiotherapy departments are multi-system-dependent envi-

ronments that rely heavily on transfer of data between patient,

machine and processing systems.

Over the last decade, the rapid development of new technology

has significantly changed the way in which radiotherapy is

planned and delivered. Three-dimensional computed tomography

(CT)-based planning, multi-leaf collimation (MLC), improved

0167-8140/$ - see front matter 2009 World Health Organization. Published by Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.radonc.2009.03.007

* Corresponding author. Address: The Collaboration for Cancer Outcomes,

Research and Evaluation (CCORE), South Western Clinical School, University of

New South Wales, Liverpool Health Service, Locked Bag 7103, Liverpool BC, NSW

1871, Australia.

E-mail address:[email protected](J. Shafiq).

Radiotherapy and Oncology 92 (2009) 1521

Contents lists available at ScienceDirect

Radiotherapy and Oncology

j o u r n a l h o m e p a g e : w w w . t h e g r e e n j o u r n a l . c o m
mailto:[email protected]://www.sciencedirect.com/science/journal/01678140http://www.thegreenjournal.com/http://www.thegreenjournal.com/http://www.sciencedirect.com/science/journal/01678140mailto:[email protected]


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immobilization, and more sophisticated planning software now

permit complex treatment plans to be developed for many patients

[14]. The increased complexity of planning and treatment and ra-

pid adoption of newtechnologies in the setting of increased patientvolume may thus create an environment with more potential for

treatment mishaps to occur. Especially, in the low and middle in-

come countries there may be old systems with less interconnectiv-

ity and fewer trained QA personnel. In addition, technologies

intended to reduce the risk of treatment inaccuracy might para-

doxically act as a new source of error[15].

Research on radiotherapy safety focuses on analyses of adverse

events and near misses[16,17]as these might lead to the identifi-

cation of latent problems and weak links within a system that lie

dormant for some time and then combine with a local trigger to

create an incident [18]. The reporting of near misses has been iden-

tified as a valuable tool in preventing serious incidents in the non-

medical domain [19]. Although detailed reports of some major

clinical radiation adverse events in the last 30 years[20,21]havebeen published, it is likely that many more have occurred but

either went unrecognised or failed to be reported to the regulatory

authorities or were not published in the literature [13]. Errors in

software or treatment machine calibration do affect hundreds of

patients and usually are well documented[13,22]. Random errors

may affect individual patients and are more difficult to be discov-

ered and prevented.

Presented below are a collation and synthesis of evidence on

radiation incidents and the recommended safety measures. Both

published literature and unpublished data sources have been re-

viewed. The areas of the highest risk in the process of care for

radiotherapy have been identified. The risk issues require further

attention, especially those not related to equipment and system

failure and modifiable through competency-based training of staffand changes in work practice culture in radiotherapy departments.

Aim

Our aim was to conduct an evidence-based review of current

practice of patient safety measures in radiotherapy treatment facil-

ities including an analysis of the previous incidents in radiotherapy

delivery and identification of high risk areas through elaborate

search of published literature and unpublished gray literature.

Materials and methods

Search strategy and selection criteria

The terminology in patient safety can be confusing and in addi-

tion clinical specialities have developed their own terminologies.

According to the WHO World Alliance for Patient Safety taxonomy

contained within the International Classification for Patient Safety

[23]the medical safety incidents are defined as:

A patient safety incident is an event or circumstance which

could have resulted, or did result, in unnecessary harm to a

patient.

An adverse event is an incident which results in harm to a

patient.

A near miss is an incident that did not cause harm (also known

as a close call).

An error is a failure to carry out a planned action as intended or

application of an incorrect plan, and may manifest by doing the

wrong thing (an error of commission) or by failing to do the right

thing (an error of omission), at either the planning or execution

phase.

According to the International Nuclear Event Scale (INES) de-

scribed in the IAEA safety glossary an Incident (level 2) is defined

as An event involving significant failure in safety provisions, but

with sufficient defence in depth remaining to cope with additional

failures and Near miss is defined as A potential significant event

that could have occurred as the consequence of a sequence of ac-

tual occurrences but did not occur owing to the plant conditionsprevailing at the time[24].

We have used the INES definitions of Incident and Near Miss

described in the IAEA safety glossary wherever possible within this

report because this is the commonest taxonomy in the literature.

However, this needs further discussion within the radiotherapy

community to determine whether a uniform terminology as in

other medical fields could be used in relation to radiotherapy

safety.

We reviewed the worldwide occurrence of radiotherapy treat-

ment incidents and near misses in the last 30 years (from 1976

to 2007) through appraisal of published materials (technical re-

ports, journal articles, guidelines) and unpublished sources of

information such as radiotherapy-related incident data maintained

by the health services. An initial computer-based search of Googleand Google Scholar search engines and PubMed search of the e-

journal collections on radiotherapy, medical physics and nuclear

medicine was performed supplemented by the searches of rele-

vant links for appropriate citations and article bibliographies for

further relevant sources. The key words used were: patient safety,

radiation protection, radiotherapy accident/s, radiotherapy er-

ror/s,radiotherapy incident/s, radiotherapy overexposure, qual-

ity assurance, safety measures and variations of these terms in

combination. In addition, we performed a broader search to iden-

tify relevant literature from developing countries using the above

key words combined with the terms Asia, Africa, developing

countries, Latin America and low and middle income countries.

The bibliography of the individual literature retrieved was iter-

atively searched for additional citations. For articles published inother languages (e.g. French, Japanese), we reviewed the translated

Decision toTreat

Simulation,Imaging & Volume

Determination

Planning

TreatmentInformation

Transfer

Assessmentof Patient

Patient Set-up

TreatmentDelivery

TreatmentReview

PrescribingTreatmentProtocol

Immobilization&

Positioning

Equipment andSoftware

Commissioning

Fig. 1. Radiotherapy process of care [1].

16 Patient safety in radiotherapy


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abstracts and verified them with the study findings from other

sources in English (if available). Our search strategy further in-

cluded selection of the Grey literature (materials that are not for-

mally published) such as working papers, organisational reports

(e.g. IAEA and ICRP reports) and conference proceedings available

from web-based sources.

We also searched for radiotherapy safety-related incidents and

near misses that were available from local, national and interna-tional databases including the Radiation Oncology Safety Informa-

tion System (ROSIS) database, a voluntary web-based safety

information database for radiotherapy set by a group of medical

physicists and radiation therapists in Europe,1 data from the UK

peer review report that is in the process of publication2 and Austra-

lian State-based Department of Radiation Oncology annual incident

reports collection.3

The incidents were recorded according to the following

categories:

Description

Direct cause/s

Contributing factors

Stage/s (described as inFig. 1) of the treatment process during

which the incident occurred

Reported impact or outcome

Corrective actions and prevention of future incidents.

We explored and synthesised the data available from all sources

to find out at what stage most accidents or incidents occurred,

what were the existing deficiencies and contributing factors that

led to the errors and how these errors could have been prevented.

A conceptualisation of radiotherapy risk according to the stages of

planning and delivery of treatment was presented in the UK Chief

Medical Officers Annual Report in 2006 [25]. This led to clinical

policy recommendations for radiotherapy services in that country.

We developed this further and mapped incidents onto a grid of the

stage of care at which they occurred.

Results

Radiotherapy incidents

A summary of all widely reported major radiotherapy incidents

that led to significant harm to patients (such as radiation injury

and death) that occurred in the last three decades (19762007)

is presented in Table 1 [13,22,24,26,27,3034,3639]. The coun-

tries of occurrence were middle and high income countries in the

US, Latin America, Europe and Asia. About 3000 (N= 3125) patients

were affected and of them 38 (1.4%) patients were reported to have

died due to radiation overdose toxicity or failures due to under-

dose. Fifty-five percent of incidents (N= 1702) were in the plan-

ning stage and of the remaining 45%, incidents were due toerrors that occurred during the introduction of new systems and/

or equipment such as megavoltage machines (25%), errors in

treatment delivery (10%), information transfer (9%) or in multiple

stages (1%).

In the years from 1992 to 2007, 4616 near misses that re-

sulted in no recognisable patient harm were identified from the

published literature from European countries, Canada and the

US [14,15,18,28,29,35,40] and unpublished incident reporting

databases from Europe,1 UK2 and Australia3 (Table 1). A major

source (N= 854) of the recent non-injurious events was the

Radiation Oncology Safety Information System (ROSIS) data-

base,1 a voluntary web-based safety information database for

radiotherapy set-up by a group of radiation therapists and med-

ical physicists) in Europe. Of all such near misses without any

known harm to patients, 9% (N= 420) were related to the plan-

ning stage; 38% (N= 1732) were related to transfer of informa-tion and 18% (N= 844) to the treatment delivery stage. The

remaining 35% of the incidents occurred in the categories of pre-

scription, simulation, patient positioning or in a combination of

multiple stages.

Fig. 2describes a summary of injurious incidents including pa-

tient deaths due to radiotherapy toxicity or failure for the last

30 years (N= 3125), the highest number of injurious incidents

(N = 1702, 22% of all) was reported in the planning stage; the

number of deaths (N= 17) was also highest in this stage.

A summary of the potentially highest risk areas in the radio-

therapy process of care and the recommended interventions to im-

prove patient safety, generated through the review of both

published and unpublished radiotherapy incident reports and

through input from the international expert committee of radio-

therapy professionals involved in the development of Radiother-

apy Risk Profile, a WHO Alliance for Patient Safety initiated

radiotherapy safety project[1]is shown inTable 2.

Radiotherapy incidents in developing countries

No detailed reports on radiotherapy-related adverse events

were available from low resource countries in Asia or Africa. The

only published studies are the evaluation of the dosimetry prac-

tices in hospitals in developing countries through the IAEA and

World Health Organisation (WHO) sponsored Thermoluminescent

Dosimetry (TLD) postal dose quality audits carried out on a regular

basis [42,43]. These studies reported that facilities that operate

radiotherapy services without qualified staff or without dosimetry

equipment have poorer results than those facilities that are prop-erly staffed and equipped. Strengthening of radiotherapy infra-

structure has been recommended for the under-resourced

centres such as those in Latin America and Caribbean to improve

their audit outcomes as comparable to those of developed coun-

tries[42].

An external audit of an Asian oncology practice was able to

identify areas of need in terms of gaps in knowledge and skills

of the staff involved. The study found that about half (52%) of the

patients audited received suboptimal radiation treatment, poten-

tially resulting in compromised cure/palliation or serious morbid-

ity. Inadequate knowledge and skills and high workload of the

radiation oncology staff were described as the reasons for poor

quality of service[44].

Discussion

Although radiotherapy is perceived as risky and complex[25],

the risk of mild to moderate injurious outcome to patients from

radiotherapy errors was about 1500 per million treatment courses

that were much lower than the hospital admission rates for ad-

verse drug reaction in Canada and US (about 65,000 per million

admissions) [45]. Also the reported rate of death from adverse

events in radiotherapy (1%) was lower than the reported rates of

death from the population-based adverse event studies (about 5

14%)[46]. It is apparent that in the earlier 1990s major radiother-

apy incidents occurred mainly due to inexperience in using new

equipment and technology during radiotherapy. These errorsare now much less frequent. In more recent times errors in data

1 ROSIS database: a voluntary safety reporting system for Radiation Oncolgy.

Available from: www.rosis.info[accessed 10 September 2007].2 Optimising patient safety: reducing errors and incidents in radiotherapy. UK peer

review report (in progress), September 2007.

3 Sydney South West Cancer Services, Radiation oncology treatment relatedincident report database 2005.

J. Shafiq et al. / Radiotherapy and Oncology 92 (2009) 1521 17
http://www.rosis.info/http://www.rosis.info/


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transfer constitute the greatest bulk of radiotherapy-related inci-

dents. These incidents included transcription errors, rounding off

errors, forgotten data or interchange of data and were attributed

to human mistakes or inattention[47]. The United States Nuclear

Regulatory Commission (NRC) that maintains a large database of

radiotherapy misadministration incidents estimated that about

60% or more of misadministrations were due to human errors

[48]. It is now a well recognised challenge in radiotherapy and a

large number of preventative guidelines and safety protocols have

been established by the radiation safety-related authorities at the

local and international level [49,50,10,51,52].

The incidents in radiotherapy which are mainly related to pa-

tient assessment prior to treatment involve history, physical exam-

ination, imaging, biochemical tests, pathology reviews and errors

during radiotherapeutic decision making which involve treatment

intent, tumour type, individual physician practice and type of

equipment used [53]. Comprehensive QA protocols have been

developed that include medical aspects of the radiotherapy treat-

ment such as clinician decisions and patient assessment [7] and

are implemented in several centres in Europe. However, these pro-

tocols have not been widely adopted in the radiotherapy centres

worldwide. This has, amongst other issues, led to a systematic

reporting bias which favours certain types of incidents, particularly

those related to technology rather than clinical judgements. It is

therefore important to view the data analysed in this paper taking

this into consideration.

An evaluation of radiotherapy incident reporting using three

well-known incident data sources, namely, IAEA, ROSIS and NRC

datasets revealed relatively fewer incidents in the Prescription

domain than in the Preparation and Treatment domains [54].

According to the report of a QA meeting in the UK in 2000, much

effort has been directed at QA of system and equipment-related

components of radiotherapy such as planning computers, dosime-

try audit and machine performance. Few initiatives have been ta-

ken to standardize medical processes including target drawing,

the application of appropriate margins and the verification of set-

up involved in radiotherapy [55]. These errors may cause varia-

tions in target delineation leading to changes in the biological

doses that have the potential for a significant impact in patient

safety.

Studies of radiotherapy practice have shown that the develop-

ment of an explicit and uniform protocol for implementation and

timely assessment of error rates can ensure that incidents are re-

duced to the lowest possible level[14,29]. Systematic minor errors

often suggest problems with infrastructure or information man-

agement that may carry an inherent risk of more serious errors.

Holmberg and McClean[18]claimed that detection and correction

of near misses through practice of a systematic multilayered pre-

treatment check-up system in their centre was preventing occur-

rence of about 14 adverse events per 1000 treatment plans. An-

other recent evaluation at a cancer centre in the United Kingdom

reported a significant decrease in the number of recorded incidents

Table 1

Chronological summary of radiotherapy incidents and near misses by region and country.

Country Year(s) Causes/contributing factors Incidents with

harm (n)

Near misses

(n)

References

Toxicity Death

USA 19741976 Co-60 unit wrong decay chart 426 [26]

19851987 Therac-25 software programming error 6 3 [27]

1992 Patient sent home with brachytherapy source left inside 1 [26]

19992000 Incorrect data entry, errors in treatment site identification 9 [15]a

Canada 19891996 Errors in indications for radiotherapy, choice of dose and target

volume critical structures at risk, inhomogeneous dose distribution

234 [28]

19922002 Incorrect treatment plan parameters, data transfer/data

generation errors, errors due to inadequate communication,

incorrect placement of accessories

596 [29]

19972002 Incomplete/incorrect prescription, record and verify (R and V)

system programming errors, calculation errors

555 [14]

20042007 Incorrect output determinations for field sizes 326b [30,31]

Costa Rica 1996 Co-60 unit calibration error 114 6 [32]

Panama 20002001 Wrong data entry into the Computerized Treatment Planning System (TPS) 28 11 [33]

UK 19821991 Inappropriate commissioning of TPS 1045b [24]

1988 Co-60 unit calibration error 250 [13]

19881989 Cs-137 brachytherapy source identification error 22 [13]

20002006 Incorrect treatment plan parameters, data transfer errors,

errors in patient positioning, field size

28 UK peer review1

20052006 Linac data management system updating error 5 1 [22,34]

Germany 19861987 Co-60 unit wrong dose table 86 [13]Spain 1990 Linear accelerator (Linac) maintenance error 27 9 [26]

Belgium 19951997 Incomplete/incorrect prescription and calculation errors 1769 [35]

Ireland 19982000 Errors related to TPS utilisation, calculation, and documentation 177 [18]

Poland 2001 Failure of safety recheck on a Linac after power failure 5 [36]

France 20042005 Linac updating error and misinformation errors 25 6 [37,38]

Europe (not specified) 20012007 Incorrect treatment plan parameters, data transfer/data generation errors,

miscommunication errors, errors related to patient identification,

bolus application and block/wedge placement

854 ROSIS database2

Japan 19902004 Errors related to TPS updating, errors due to inadequate communication 734 1 [39]

Australia 19931995 Errors in prescriptions and planning 235 [40]

2005 Incorrect treatment plan parameters, data transfer/data

generation errors, and errors related to bolus application, shielding

159 (SAC 13)c SSW Cancer Services3

All incidents 3087 38 4616

a The incidents described were the ones only related to the computerised record and verify system.b Radiation underdose of 335% may have lead to high rate of local recurrence.c Severity Assessment Code (SAC) is a numerical score applied to an incident based on the type of event, its likelihood of recurrence and its consequence. The scale ranges

from 1 (extreme) to 4 (low) [41].



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6

1713

2

790

1685

276

304

32

3087

38

1

10

100

1000

10000

Immobilization&positioning

Simulation&imaging

Commissioning

Planning

Treatmentinformationtransfer

Patientset-up&verification

Treatmentdelivery

Treatmentreview

MultiplestagesTotal

Numberof

incidents

Death Overdose/underdose N = 3125

Fig. 2. Radiotherapy incidents with adverse patient outcomes (19762007) by stage of treatment.

Table 2

Potential risk areas ( )a in radiotherapy treatment.

Stages Patient factors Equipment or

system factors

Staff factors Suggested preventive

measures

History Clinical

examination

Pathology Communication Guidelines/

protocol

Training No. of

staff

Patient assessment and

decision to treat

Peer review process

Evidence-based

practice

Prescribing treatment

protocol

Peer review process

Standard protocol Competency

certification

Consultation with

seniors

Immobilisation and

positioning

Competency

certification

QA check and feedback

Incident monitoring

Simulation and Imaging Competency

certification

QA check and feedback

Incident monitoring

Planning QA check and feedback

New staff and equip-

ment orientation

Competency

certification

Incident monitoring

Treatment information

transfer

Clear documentation

Treatment sheet check

Record and verify

system

In vivo dosimetry

Patient set-up Competency

certification

Incident monitoring

Supervisor audit

Treatment delivery Incident monitoring

Imaging/portal film

In-vivo dosimetry

Treatment review Competency

certification

Incident monitoring

Independent audit

a Priority measures suggested for the factors with mark in all stages.



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over the past eight years. Changes in working practices during that

time such as relocation of different procedures, increased use of

specialist staff and regular discussion amongst staff regarding

changes in relation to the requirements of new technology were

identified as factors promoting incident reduction[56].

An important initiative in preventing radiotherapy errors in

decision making and poor or incorrect work practice could be

behavioural modification achieved through frequent audit and reg-ular peer review of the specialists protocols, processes, procedures

and personnel involved[6,57]. Shakespeare et al. [44] observed

that their audit acted as an informal learning needs assessment

for the radiation oncology staff of the audited centre. They became

more aware of their knowledge and skills gaps and implemented

peer review of all patients simulated, weekly departmental contin-

uing medical education activities, a portal film review process and

have been performing literature search and peer discussion of dif-

ficult cases. They recommended that the establishment of an ade-

quate radiation oncology training system, preferably one based on

available evidence, is an essential element of improved safety prac-

tice, especially in the low income countries [44]. Any investment in

resource development (e.g. time, personnel, and training) would

vary from country to country because of the variability of the

radiotherapy workforce-related costs between high, middle and

low income countries [58]. European experts suggested that taking

initiatives to improve the culture of clinical governance and setting

the standards of practice through medical peer review of target

drawing and dose prescription would be a significant positive step

in improving the quality of radiotherapy services[55].

In our review, we have added a descriptive summary of inci-

dents categorized according to the stage, examined the causes,

contributing factors, suggestions and recommendations that were

made. The sources that were found described a wide variety of

incidents that occurred all through the radiotherapy process.

Though a large proportion of reported incidents were related to

the system failures due to incorrect use of equipment and set-up

procedures, for a number of them the contributing factors were

incorrect treatment decisions, incorrect treatment delivery andinadequate verification of treatment due to inexperience and inad-

equate knowledge of the staff involved. These errors were not as

well reported as the system-related errors documented predomi-

nantly by the medical physicists, as observed in our review.

The severity of incidents was not described with a standardised

system and incidents were not collected prospectively. It was not

possible to compare severity between incidents except when the

incident resulted in death. Hence, development of a set of stan-

dards highlighting the patient-centred risk areas in radiotherapy

treatment with suggested improvements tailored to the need of

individual countries and specific departments would be relevant

for all stakeholders. Each radiotherapy service should individually

and repeatedly examine its risk profile and incidents as well as

near misses should be prospectively collected, measured andcategorised.

Conclusion

Radiotherapy-related errors are not uncommon even in the

countries with the highest level of health care resources but

the error rates compare favourably with the rate of other med-

ical errors[46]. It is unrealistic to expect to reduce the error rate

to zero but every effort should be taken to keep the rates low.

Risk model researchers Duffy and Saull say Errors can always

be reduced to the minimum possible consistent with the accu-

mulated experience by effective error management systems

and tracking progress in error reduction down the learning

curve [48]. This can also lead to the identification of incidentsearlier in the process with less serious consequences.

The WHO World Alliance for Patient Safety has taken an ini-

tiative to address the risk areas in the radiotherapy process of

care that is complimentary to the IAEA developed safety mea-

sures and other previously developed standards[1]. Frequent for-

mal and informal staff communication, competency-based

training and regular audits to assess adherence to the protocols

are the top three areas that need to be focused to improve safety

in radiotherapy process.

Role of the funding source

The authors alone are responsible for the views expressed in

this publication and they do not necessarily represent the deci-

sions, policy or views of the World Health Organisation.

Acknowledgements

This paper was funded and supported by the WHO World Alli-

ance for Patient Safety as part of the Radiotherapy Safety Initiative.

Available from: http://www.who.int/patientsafety/activities/tech-

nical/radiotherapy/en/index.html.

Avenue Appia 20, CH-1211 Geneva 27, Switzerland.

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