Systematic review| Volume 92, ISSUE 1, P15-21, July 2009

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An international review of patient safety measures in radiotherapy practice


      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 discovered 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 internationally 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the aim of identifying the domains where most errors occur through extensive review and synthesis of published reports, unpublished ‘Grey literature’ and departmental incident data.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 (1976–2007) 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 recognisable 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.


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      1. World Health Organization (WHO). Radiotherapy risk profile: technical manual. Geneva: WHO; 2009. Available from: http://www/ [accessed 02 February 2009].

        • Delaney G.
        • Jacob J.
        • Featherstone C.
        • Barton M.
        The role of radiotherapy in cancer treatment: estimating optimal utilization from a review of evidence-based clinical guidelines.
        Cancer. 2005; 104: 1129-1137
      2. The Swedish council on technology assessment in health care (SBU). Systematic overview of radiotherapy for cancer including a prospective survey of radiotherapy practice in Sweden 2001 – summary and conclusions. Acta Oncol 2003;42:357–65.

      3. Holmberg O. Accident prevention in radiotherapy. Biomed Imaging Interv J 2007;3:e27. Available from: [accessed 18 June 2007].

      4. World Health Organization (WHO). Quality assurance in radiotherapy. Geneva: WHO; 1988.

      5. European Commission. Guidelines on education and training in radiation protection for medical exposures. Radiation protection 116. Luxembourg: Environment Directorate-General, Office for Official Publications of the European Communities; 2000.

      6. Comprehensive audits of radiotherapy practices: a tool for quality improvement: Quality Assurance Team for Radiation Oncology (QUATRO). Vienna: International Atomic Energy Agency; 2007.

      7. Setting up a radiotherapy programme: clinical, medical physics, radiation protection and safety aspects. Vienna: International Atomic Energy Agency (IAEA); 2008.

      8. International Commission on Radiological Protection (ICRP). Radiological protection and safety in medicine. ICRP 73. Ann ICRP 1996;26:1–47.

        • Kutcher G.J.
        • Coia L.
        • Gillin M.
        • et al.
        Comprehensive QA for radiation oncology: report of AAPM Radiation Therapy Committee Task Group 40.
        Med Phys. 1994; 21: 581-618
      9. Leer JW, Mckenzie A, Scalliet P, Thwaites DI. Practical guidelines for the implementation of a quality system in radiotherapy. ESTRO physics for clinical radiotherapy booklet No. 4. Brussels, Belgium: European Society for Therapeutic Radiology and Oncology (ESTRO); 1998.

        • Novotny J.
        • Izewska J.
        • Dutreix A.
        • van der Schueren E.
        A quality assurance network in Central European countries: radiotherapy infrastructure.
        Acta Oncol. 1998; 37: 159-165
      10. Prevention of accidental exposures to patients undergoing radiation therapy: a report of the International Commission on Radiological Protection (ICRP). Ann ICRP 2000;30:7–70.

        • Huang G.
        • Medlam G.
        • Lee J.
        • et al.
        Error in the delivery of radiation therapy: results of a quality assurance review.
        Int J Radiat Oncol Biol Phys. 2005; 61: 1590-1595
        • Patton G.
        • Gaffney D.
        • Moeller J.
        Facilitation of radiotherapeutic error by computerized record and verify systems.
        Int J Radiat Oncol Biol Phys. 2003; 56: 50-57
        • Holmberg O.
        • McClean B.
        Preventing treatment errors in radiotherapy by identifying and evaluating near misses and actual incidents.
        J Radiother Pract. 2002; 3: 13-25
        • Williams M.V.
        Improving patient safety in radiotherapy by learning from near misses, incidents and errors.
        Br J Radiol. 2007; 80: 297-301
        • Hamilton C.
        • Oliver L.
        • Coulter K.
        How safe is Australian radiotherapy?.
        Australas Radiol. 2003; 47: 428-433
        • Barach P.
        • Small S.D.
        Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.
        Br Med J. 2000; 320: 759-763
      11. International Atomic Energy Agency (IAEA). Lessons learned from accidents in radiotherapy. Safety reports series 17. Vienna, Austria: IAEA; 2000.

      12. Ortiz P, Oresegun M, Wheatley J. Lessons from major radiation accidents. IAEA publication. Available from: [accessed 11 October 2007].

        • Ash D.
        • Bates T.
        Report on the clinical effects of inadvertent radiation underdosage in 1045 patients.
        Clin Oncol. 1994; 6: 214-225
      13. International Classification for Patient Safety (ICPS). World Health Organisation (WHO). Available from: [accessed 24th June 2008].

      14. IAEA safety glossary: terminology used in nuclear safety and radiation protection; 2007. Available from: [accessed 30 July 2008].

      15. UK Department of Health. Radiotherapy: hidden dangers. In: On the state of public health: annual report of the Chief Medical Officer 2006. London: Department of Health; 2007. p. 61–8 [chapter 5].

      16. International Atomic Energy Agency. Short case histories of major accidental exposure events in radiotherapy. Available from: [accessed 20 September 2007].

        • Leveson N.G.
        • Turner C.S.
        An investigation of the Therac-25 accidents.
        IEEE Comput. 1993; 26: 18-41
        • Brundage M.D.
        • Dixon P.F.
        • Mackillop W.J.
        • et al.
        A real-time audit of radiation therapy in a regional cancer center.
        Int J Radiat Oncol Biol Phys. 1999; 43: 115-124
        • Yeung T.K.
        • Bortolotto K.
        • Cosby S.
        • et al.
        Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period.
        Radiother Oncol. 2005; 74: 283-291
      17. MacLeod I. Cancer patients get wrong dose at Civic Campus. The Ottawa Citizen; 2008 [July 21].

      18. Gandhi U. 326 skin cancer patients underdosed because of hospital error. Globe Mail 2008:A6 [July 22].

      19. International Atomic Energy Agency. The overexposure of radiotherapy patients in San José, Costa Rica. Vienna, Austria: IAEA; 1998 [STI/PUB/1180].

      20. International Atomic Energy Agency. Investigation of an accidental exposure of radiotherapy patients in Panama. Vienna, Austria: IAEA; 2001 [STI/PUB/1114].

      21. Unintended overexposure of patient Lisa Norris during radiotherapy treatment at the Beatson Oncology Centre, Glasgow in January 2006. Report of the investigation by Inspector appointed by the Scottish Ministers for the Ionising Radiation (Medical Exposures) Regulations; 2000. Available from: [accessed 11 October 2007].

        • Bate M.T.
        • Speleers B.
        • Vakaet A.M.L.
        • De Neve W.J.
        Quality control and error detection in the radiotherapy treatment process.
        J Radiother Pract. 1999; 1: 125-134
      22. International Atomic Energy Agency. The accidental overexposure of radiotherapy patients in Bialystok. Vienna, Austria: IAEA; 2002 [STI/PUB/1027].

      23. Autorite De Surate Nucleaire (ASN). Annual report 2006. Available from: [accessed 11 October 2007].

      24. Summary of ASN report no. 2006 ENSTR 019 – IGAS no. RM 2007-015P on the Epinal radiotherapy accident, submitted by Guillaume Wack (ASN, the French Nuclear Safety Authority) and Dr. Françoise Lalande, member of the Inspection Générale des Affaires Sociales (General inspectorate of Social Affairs), in association with Marc David Seligman. Available from: [accessed 23 October 2007].

      25. Hiroshi I, Naofumi H, Masahiro E, et al. How do we overcome recent radiotherapy accidents? A report of the symposium held at the 17th JASTRO Annual Scientific Meeting, Chiba, 2004 [Abstract]. J JASTRO (Japanese Society for Therapeutic Radiology and Oncology) 2005;17:133–9. Available from: [accessed 13 November 2007].

        • Duggan L.
        • Kron T.
        • Howlett S.
        • et al.
        An independent check of treatment plan, prescription and dose calculation as a QA procedure.
        Radiother Oncol. 1997; 42: 297-301
      26. The Clinical Excellence Commission of New South Wales. Patient safety clinical incident management in NSW. Analysis of 1st year of IIMS (Incident Information Management System) data; annual report 2005–2006. Sydney; 2006.

        • Izewska J.
        • Andreo P.
        • Vatnitsky S.
        • Shortt K.R.
        The IAEA/WHO TLD postal dose quality audits for radiotherapy: a perspective of dosimetry practices at hospitals in developing countries.
        Radiother Oncol. 2003; 69: 91-97
      27. Izewska J, Vatnitsky S, Shortt KR for IAEA. Postal dose audits for radiotherapy centers in Latin America and the Caribbean: trends in 1969–2003. Rev Panm Salud Publica 2006;20:161–72.

        • Shakespeare T.P.
        • Back M.F.
        • Lu J.J.
        • et al.
        External audit of clinical practice and medical decision making in a new Asian oncology center: results and implications for both developing and developed nations.
        Int J Radiat Oncol Biol Phys. 2006; 64: 941-947
        • Munro A.J.
        Hidden danger, obvious opportunity: error and risk in the management of cancer.
        Br J Radiol. 2007; 80: 955-966
        • Vincent C.
        Clinical risk management: enhancing patient safety.
        2nd ed. BMJ Books, London, UK2001
        • Leunens G.
        • Verstraete J.
        • Bogaert W.
        • et al.
        Human errors in data transfer during the preparation and delivery of radiation treatment affecting the final result: “garbage in, garbage out”.
        Radiother Oncol. 1992; 23: 217-222
      28. Duffey RB, Saull JW. Know the risk: learning from errors and accidents: safety and risk in today’s technology. US: Butterworth-Heinemann Publications; 2003, ISBN 0-7596-9.

      29. International Atomic Energy Agency (IAEA). Applying radiation safety standards in radiotherapy. Vienna, Austria: IAEA; 2006 [safety reports series no. 38].

      30. Thwaites DI, Mijnheer BJ, Mills JA. Quality assurance of external beam radiotherapy. In: International Atomic Energy Agency (IAEA). Radiation oncology physics: a handbook for teachers and students. Vienna, Austria: IAEA; 2005. p. 407–50 [chapter 12]. Available from: [accessed 30 October 2007].

      31. American Association of Physicists in Medicine (AAPM). Quality assurance for clinical radiotherapy treatment planning. College Park, MD: AAPM; 1998 [AAPM report 62].

      32. Canadian Association of Provincial Cancer Agencies. Standards for Quality Control at Canadian Radiation Treatment Centres: Kilovoltage X-ray Radiotherapy Machines. Available from: [accessed 29 October 2007].

        • Esik O.
        • Seitz W.
        • Lovey J.
        • et al.
        External audit on the clinical practice and medical decision-making at the departments of radiotherapy in Budapest and Vienna.
        Radiother Oncol. 1999; 51: 87-94
        • Ekaette E.U.
        • Lee R.C.
        • Cooke D.L.
        • et al.
        Risk analysis in radiation treatment: application of a new taxonomic structure.
        Radiother Oncol. 2006; 80: 282-287
        • McNee S.G.
        Clinical governance: risks and quality control in radiotherapy. Report on a meeting organized by the BIR Oncology Committee, held at the British Institute of Radiology, London, on 9 February 2000 [Commentary].
        Br J Radiol. 2001; 74: 209-212
        • Lawrence G.
        • Bennett D.
        • Branson A.
        • et al.
        The Impact of changing technology and working practices on errors at the NCCT 1998–2006.
        Clin Oncol (R Coll Radiol). 2007; 19: S37
        • Shakespeare T.P.
        • Back M.F.
        • Lu J.J.
        • et al.
        Design of an internationally accredited radiation oncology training program incorporating novel educational models.
        Int J Radiat Oncol Biol Phys. 2004; 59: 1157-1162
        • Van Der Giessen P.H.
        • Alert J.
        • Badri C.
        • et al.
        Multinational assessment of some operational costs of teletherapy.
        Radiother Oncol. 2004; 71: 347-355