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5 Ways to Prevent Radiation Therapy Errors

Cheryl Clark, for HealthLeaders Media, August 8, 2011

With increased attention on patients harmed and nearly harmed, by radiation therapy errors, researchers at two hospitals say they have isolated five checks, which, if used consistently, would have prevented 97% of 4,000 errors and near misses identified in a three-year period.

"The key to this whole thing,  to learn and improve the quality of our treatments and patient safety,  is to look carefully at what happens in our (radiation clinics) and paying attention to these near misses," said Eric Ford, assistant professor of radiation oncology and Molecular Radiation Sciences at Johns Hopkins University.

"We call it a free lesson; it doesn't hurt anyone, although it comes close, but we have learned from that."

Ford and researchers at Washington University in St. Louis, gathered voluntarily contributed information on about 4,000 errors and near misses that occurred during cancer care at the two hospitals and scrutinized 290, which would have resulted in serious harm, such as radiation to the wrong body part or wrong dosage.

They then looked at 13 commonly employed quality assurance measures to see which ones would have had the great likelihood of catching the error or near miss before it occurred. 

They narrowed it down to these five:
  1. Use of  an Electronic Portal Imaging Device or EPID would gave caught about 83%
  2. Treatment plan check by a physicist would have caught 63%.
  3. Use of port films would have caught 53% of errors.
  4. Check by the radiation therapist would have caught 35%.
  5.  Proper use of standard radiation therapy checklists, such as assuring that
  • The patient is the correct patient
  • The patient is not pregnant
  • Treatment is directed at correct body part,
  • Both physicians and radiation physicists have reviewed patient charts to calculate the correct radiation dose also had a significant error capture success rate.
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