Their report was presented as an abstract last week at the joint American Association of Physicists in Medicine (AAPM) and Canadian Organization of Medical Physicists annual meeting in Vancouver.
One finding from the research was that EPID hardware, which is now more commonly used in Europe but rarely in the U.S., is especially effective at avoiding near misses. The device is built into radiation machinery and provides a realtime image of precisely where the radiation is hitting the patient. Fewer than 1% of radiation clinics use the device because software and training are not available.
A second finding is that a quality assurance measure commonly known as "pretreatment intensity modulated radiation therapy or IMR, in which clinicians do a test run at its programmed strength with no patient present, ranked zero in effectiveness at preventing near misses and errors.
Ford and his research colleagues are calling for a "national radiotherapy incident reporting system" so that treatment errors and near misses can be sent to a central group for evaluation and dissemination to clinics.
National attention on the incidence ofharm from radiation errors has intensified since January of 2010 when a series in The New York Times revealed systemic problems in processes, error recognition and detection, and lethal consequences in many of the one million patients treated annually with radiation for cancer. The series explained how the errors were not only underreported, but under recognized, in part because the patients were already sick.
Ford said the series described some "incredibly bad radiation errors that had some horrible consequences for patients."