Safety Considerations in Radiation Therapy

Abstract

Approximately half of all cancer patients are treated with radiation therapy at some point in the management of their disease. These treatments are delivered in one of the most complex disciplines in healthcare, with the complexity and technology growing each year. In spite of this complexity a vast majority of treatments are delivered in a safe and effective manner. However, as recent data from cooperative group trials indicates there is a quality gap in the delivery of care. This underscores the need to improve care. Numerous healthcare-IT-related issues are at work in this context and two case studies serve to illustrate important causal factors. In the first case, a patient received a lethal overdose of radiation (seven times the prescribed amount) due to a single point of failure, i.e., a computer crash during the stage of preparing for the treatment. In the second case there was an accidental misalignment of the radiation field to treat the wrong location in a patient due to the misidentification of a landmark point in the computer planning interface. Though many complex factors were at work in these error scenarios, a common theme is a deficiency in the human–computer interface (HCI). HCI-related shortcoming can guide the user toward error rather than away from it. Poor HCI can also prevent staff from identifying problems as they develop. Pioneering efforts are underway to improve HCI system to help prevent errors. Efforts are also being aimed at developing new algorithms which automatically detect abnormalities in the IT systems as they develop. The newly released national incident learning system, RO-ILS™: Radiation Oncology Incident Learning System, should provide valuable information in the coming years as to common error pathways, contribution of IT systems, and methods to prevent and control error.