And while for "those of us who work in this field, this issue has never been under-appreciated," he said it's now receiving "extra attention" from health providers, including hospital leaders, and others "who didn't normally think about it."
Asked what hospital executives, physicians and radiation oncology specialists should learn from this report, Ford said:
"The most fruitful thing would be to look at the operation from a system point of view and organize yourself around that. We need to start looking at this not as an individual failing of what someone does, or a piece of the puzzle breaking, but that it's more of a system problem.
"How do you put these checks together in a coherent way to make your system work in a way that would be less inclined to let an error slip through."
Some of the strategies, Ford says, are simple "low-hanging fruit," while others may take some time and investment. But no matter what, he says, " we have to get to as close as possible to a zero rate of error."