And second, radiation treatment plans are more complex, "leaving very narrow margin for error," the report states.
Administering the wrong dose, or treating the wrong site or patient are all caused by human error, software problems, and provider or operator inexperience with the fast pace of technological change.
For example, the report says, in one year from July 2009 to July 2010, there have been over 40 reports of software errors, manufacturing-required software modifications or dose calculation errors for radiotherapy systems, linear accelerators and radiation treatment planning systems.
The report advises hospitals to make sure personnel have up-to-date and appropriate certifications and training and that staffing levels are adequate. Maintain systems to ensure that patient treatment procedures are documented and followed, with attention to providing oversight of incident reporting and safety alerts management.
2. Alarm Hazards
Alarm-related adverse events also ranked second on last year's list.
"Clinical alarm problems were once again in the news in 2010 when the Boston Globe reported the death of a patient whose treatment may have been delayed because of a critical physiologic monitoring alarm had been turned off," authors say.