Practical Radiation Oncology (2011) 1, 188–189
www.practicalradonc.org
Commentary
Safety considerations in contemporary radiation oncology: Introduction to a series of ASTRO safety white papers Benedick A. Fraass PhD a,⁎, Lawrence B. Marks MD b , Todd Pawlicki PhD c , for the ASTRO Multidisciplinary Quality Assurance Subcommittee a
Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina c Department of Radiation Oncology, University of California San Diego, La Jolla, California b
Received 19 April 2011; accepted 28 April 2011
The issue of patient safety has been pulled to the forefront by the recent reports in the lay press, and Congressional hearings, for both radiation therapy and diagnostic imaging. A number of misadministrations described in a series of New York Times articles have triggered increased interest in improved patient safety in radiation oncology.1-3 These articles have highlighted some of the risks associated with advanced radiation therapy treatment planning and delivery systems and techniques. Many new patient safety initiatives, meetings, and other efforts have been organized to address the need to continue to enhance the safety of patients undergoing radiation therapy. As part of this effort, in January 2010 the American Society for Radiation Oncology (ASTRO) commissioned a series of “Safety White Papers” to help identify areas where improvements are necessary, so that patient safety is continually enhanced. This ASTRO initiative has involved cooperation with other organizaSee Related Article on page 190. Conflicts of interest: Dr Fraass is a member of the Varian Patient Safety Council. Dr Marks has no disclosures to report. Dr Pawlicki has received research grants from Varian, Vision RT and CIVCO, and is a cofounder of AQuSI, which performs training for radiation medicine professionals in techniques of quality and safety. ⁎ Corresponding author. Department of Radiation Oncology, CedarsSinai Medical Center, 8700 Beverly Blvd, AC1023, Los Angeles, CA 90048. E-mail address: [email protected] (B.A. Fraass).
tions, including the American Association of Physicists in Medicine and the American Brachytherapy Society. The papers have been written by small interdisciplinary teams, reviewed by groups of experts, and subjected to a public comment period. The first paper in this series, “Safety considerations for intensity modulated radiation therapy: executive summary,” by Moran et al,4 addresses safety and quality issues for intensity modulated radiation therapy (IMRT). Other white papers to follow will address stereotactic body radiation therapy, high-dose-rate brachytherapy, imageguided radiation therapy (IGRT), and peer review in radiation oncology. Additional reports and updates will follow as radiation therapy techniques and devices evolve. Safety issues for any of these complex technologies cannot be effectively summarized briefly. Therefore, the initial objective for the white papers is to quickly identify issues that would benefit from immediate attention. Thus, the goals of the white papers are the following: (1) To provide an overview of issues that should be addressed within a broad safety program for these kinds of treatments (eg, in the first paper, concentrating on IMRT); and (2) to make recommendations to the radiation oncology community which identify issues that require new approaches, new guidance, or other modifications of current safety and quality assurance methods. These documents are not intended to be general and complete treatises on everything that has been done, or to
1879-8500/$ – see front matter © 2011 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.prro.2011.04.009
Practical Radiation Oncology: July-September 2011
be technical documents describing exactly what should be done. Rather, the white papers will try to describe the major issues and general ways to address those issues. The intended audience is radiation oncology professionals, including radiation oncologists, physicists, therapists, dosimetrists, nurses, radiation oncology administrators, and vendors; in other words, all the people who can directly make changes that will improve safety in the field. The papers will refer to published guidance, when available, as there is a huge array of important guidance documents already published by many different radiation oncology organizations. However, there will be places where the current white papers will conflict with current guidance; where practical, these differences will be highlighted. Modifications of existing safety guidance reflect the need to continually examine, improve, and enhance safety and quality. The writing groups for these white papers have a challenging task and we are indebted to them for their efforts. It is difficult to explain complex procedures, associated quality and safety concerns, and potential solutions in a concise and actionable manner. These techniques (eg, IMRT, IGRT, etc) are multifaceted and their successful implementation requires the concerted efforts of many individuals. Further, many of the white papers, and especially the IMRT white paper, have included information that is not technique specific but applies broadly to other types of radiation therapy as well. For example, the IMRT paper contains a description of efforts needed to create and maintain a culture of safety, an issue that should apply to all radiotherapy efforts. Safety and quality are different but related concepts. Safety generally relates to preventing errors (frankly right versus wrong decisions and actions) that can have major therapeutic implications (eg, treatment of the wrong
Safety considerations in radiation oncology
189
patient, treatment with the wrong plan, incorrect placement of a block or wedge, failure to correctly transfer electronic data between the various computer systems). On the other hand, quality often relates more to somewhat subjective issues such as assuring that the defined volumes, doses, beams, etc, are clinically appropriate, and that the treatment is delivered as prescribed within acceptable clinical tolerance limits. These white papers attempt to concentrate on addressing safety issues. However, all of the white papers include some material related primarily to quality, since the issues of safety and quality are most certainly intertwined; quality can decrease to the point that it becomes a safety issue. To summarize, the “Safety” white paper effort is part of a long-standing tradition of a continuous focus on quality and safety in radiation oncology. These papers serve to increase awareness of safety issues, and offer recommendations to the radiation oncology community to streamline and improve safety throughout the field. We hope that these efforts will serve to improve the quality and assure the safety of the treatments delivered to our patients.
References 1. Bogdanich W. Radiation offers new cures, and ways to do harm. NY Times. 2010. http://www.nytimes.com/2010/01/24/health/ 24radiation.html. Accessed June 13, 2011. 2. Bogdanich W, Ruiz RR. Radiation errors reported in Missouri. NY Times. 2010. http://www.nytimes.com/2010/02/25/us/25radiation. html. Accessed June 13, 2011. 3. Bogdanich W, Rebelo K. A pinpoint beam strays invisibly, harming instead of healing. NY Times. 2010. http://www.nytimes.com/ 2010/12/29/health/29radiation.html. Accessed June 13, 2011. 4. Moran JM, Dempsey M, Eisbruch A, et al. Safety considerations for IMRT: Executive summary. Pract Radiat Oncol. 2011;1:190-195.
www.practicalradonc.org
Commentary
Safety considerations in contemporary radiation oncology: Introduction to a series of ASTRO safety white papers Benedick A. Fraass PhD a,⁎, Lawrence B. Marks MD b , Todd Pawlicki PhD c , for the ASTRO Multidisciplinary Quality Assurance Subcommittee a
Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina c Department of Radiation Oncology, University of California San Diego, La Jolla, California b
Received 19 April 2011; accepted 28 April 2011
The issue of patient safety has been pulled to the forefront by the recent reports in the lay press, and Congressional hearings, for both radiation therapy and diagnostic imaging. A number of misadministrations described in a series of New York Times articles have triggered increased interest in improved patient safety in radiation oncology.1-3 These articles have highlighted some of the risks associated with advanced radiation therapy treatment planning and delivery systems and techniques. Many new patient safety initiatives, meetings, and other efforts have been organized to address the need to continue to enhance the safety of patients undergoing radiation therapy. As part of this effort, in January 2010 the American Society for Radiation Oncology (ASTRO) commissioned a series of “Safety White Papers” to help identify areas where improvements are necessary, so that patient safety is continually enhanced. This ASTRO initiative has involved cooperation with other organizaSee Related Article on page 190. Conflicts of interest: Dr Fraass is a member of the Varian Patient Safety Council. Dr Marks has no disclosures to report. Dr Pawlicki has received research grants from Varian, Vision RT and CIVCO, and is a cofounder of AQuSI, which performs training for radiation medicine professionals in techniques of quality and safety. ⁎ Corresponding author. Department of Radiation Oncology, CedarsSinai Medical Center, 8700 Beverly Blvd, AC1023, Los Angeles, CA 90048. E-mail address: [email protected] (B.A. Fraass).
tions, including the American Association of Physicists in Medicine and the American Brachytherapy Society. The papers have been written by small interdisciplinary teams, reviewed by groups of experts, and subjected to a public comment period. The first paper in this series, “Safety considerations for intensity modulated radiation therapy: executive summary,” by Moran et al,4 addresses safety and quality issues for intensity modulated radiation therapy (IMRT). Other white papers to follow will address stereotactic body radiation therapy, high-dose-rate brachytherapy, imageguided radiation therapy (IGRT), and peer review in radiation oncology. Additional reports and updates will follow as radiation therapy techniques and devices evolve. Safety issues for any of these complex technologies cannot be effectively summarized briefly. Therefore, the initial objective for the white papers is to quickly identify issues that would benefit from immediate attention. Thus, the goals of the white papers are the following: (1) To provide an overview of issues that should be addressed within a broad safety program for these kinds of treatments (eg, in the first paper, concentrating on IMRT); and (2) to make recommendations to the radiation oncology community which identify issues that require new approaches, new guidance, or other modifications of current safety and quality assurance methods. These documents are not intended to be general and complete treatises on everything that has been done, or to
1879-8500/$ – see front matter © 2011 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.prro.2011.04.009
Practical Radiation Oncology: July-September 2011
be technical documents describing exactly what should be done. Rather, the white papers will try to describe the major issues and general ways to address those issues. The intended audience is radiation oncology professionals, including radiation oncologists, physicists, therapists, dosimetrists, nurses, radiation oncology administrators, and vendors; in other words, all the people who can directly make changes that will improve safety in the field. The papers will refer to published guidance, when available, as there is a huge array of important guidance documents already published by many different radiation oncology organizations. However, there will be places where the current white papers will conflict with current guidance; where practical, these differences will be highlighted. Modifications of existing safety guidance reflect the need to continually examine, improve, and enhance safety and quality. The writing groups for these white papers have a challenging task and we are indebted to them for their efforts. It is difficult to explain complex procedures, associated quality and safety concerns, and potential solutions in a concise and actionable manner. These techniques (eg, IMRT, IGRT, etc) are multifaceted and their successful implementation requires the concerted efforts of many individuals. Further, many of the white papers, and especially the IMRT white paper, have included information that is not technique specific but applies broadly to other types of radiation therapy as well. For example, the IMRT paper contains a description of efforts needed to create and maintain a culture of safety, an issue that should apply to all radiotherapy efforts. Safety and quality are different but related concepts. Safety generally relates to preventing errors (frankly right versus wrong decisions and actions) that can have major therapeutic implications (eg, treatment of the wrong
Safety considerations in radiation oncology
189
patient, treatment with the wrong plan, incorrect placement of a block or wedge, failure to correctly transfer electronic data between the various computer systems). On the other hand, quality often relates more to somewhat subjective issues such as assuring that the defined volumes, doses, beams, etc, are clinically appropriate, and that the treatment is delivered as prescribed within acceptable clinical tolerance limits. These white papers attempt to concentrate on addressing safety issues. However, all of the white papers include some material related primarily to quality, since the issues of safety and quality are most certainly intertwined; quality can decrease to the point that it becomes a safety issue. To summarize, the “Safety” white paper effort is part of a long-standing tradition of a continuous focus on quality and safety in radiation oncology. These papers serve to increase awareness of safety issues, and offer recommendations to the radiation oncology community to streamline and improve safety throughout the field. We hope that these efforts will serve to improve the quality and assure the safety of the treatments delivered to our patients.
References 1. Bogdanich W. Radiation offers new cures, and ways to do harm. NY Times. 2010. http://www.nytimes.com/2010/01/24/health/ 24radiation.html. Accessed June 13, 2011. 2. Bogdanich W, Ruiz RR. Radiation errors reported in Missouri. NY Times. 2010. http://www.nytimes.com/2010/02/25/us/25radiation. html. Accessed June 13, 2011. 3. Bogdanich W, Rebelo K. A pinpoint beam strays invisibly, harming instead of healing. NY Times. 2010. http://www.nytimes.com/ 2010/12/29/health/29radiation.html. Accessed June 13, 2011. 4. Moran JM, Dempsey M, Eisbruch A, et al. Safety considerations for IMRT: Executive summary. Pract Radiat Oncol. 2011;1:190-195.
