title: [Accidents in radiotherapy: historical account].
abstract: Radiotherapy accidents are exceedingly rare. However, they may have major negative consequences: for health (and sometimes life) of victims as well as for the trust that patients put in radiotherapy and radiation oncologists. Each accident must be pointed out, analysed and reported, in order to allow preventive actions, avoiding repetitive accidents. Through examples of majors accidents occurred all over the world in the last decades, affecting professionals, public or patients themselves, the necessity of transparency is demonstrated. The International Commission of Radiobiological Protection has drawn positive lessons from such accidents and insists on following recommendations: necessity of sufficient number and competent professionals, importance of continuous and initial education, information of professionals and, in general, a strict Quality Assurance program. It is clear that each radiotherapy center remains at risk for errors. It is essential to develop preventive procedures to avoid transformation of errors into accidents. In that context, complete and detailed description and reports of each anomaly or incident must be encouraged as it is done for sectors of aviation or nuclear industry. Radiation oncology must develop such a culture of transparency and of systematic report of all incidents.
authors.affiliation: Institut Curie, 26, rue d'Ulm, 75005 Paris, France. jean-marc.cosset@curie.net
authors.forename: J M
authors.initials: JM
authors.lastname: Cosset
authors.forename: P
authors.initials: P
authors.lastname: Gourmelon
mesh_terms: D000062:Accidents, Occupational / Q000706:statistics & numerical data; D000328:Adult; D001938:Brazil / Q000453:epidemiology; D002489:Central America / Q000453:epidemiology; D002588:Cesium Radioisotopes / Q000009:adverse effects; D002648:Child; D003037:Cobalt Radioisotopes / Q000009:adverse effects; D004866:Equipment Contamination; D004868:Equipment Failure; D004869:Equipment Safety; D005060:Europe / Q000453:epidemiology; D005260:Female; D006801:Humans; D007496:Iridium Radioisotopes / Q000009:adverse effects; D008297:Male; D019300:Medical Errors; D008800:Mexico / Q000453:epidemiology; D009656:North America / Q000453:epidemiology; D010315:Particle Accelerators; D011832:Radiation Injuries / Q000453:epidemiology* / Q000209:etiology / Q000401:mortality; D018788:Radioactive Hazard Release / Q000706:statistics & numerical data; D011867:Radioisotope Teletherapy / Q000009:adverse effects / Q000295:instrumentation; D011878:Radiotherapy / Q000009:adverse effects*; D014421:Turkey / Q000453:epidemiology
chemical_list: D002588:Cesium Radioisotopes; D003037:Cobalt Radioisotopes; D007496:Iridium Radioisotopes