title: An analysis of radiation therapy medical events in New York State: the role of the state radiation programs in patient safety.
abstract: From 2001 through 2009, the New York State Department of Health (NYSDOH) has documented 244 reports of radiation therapy events, of which 228 have resulted from the delivery of radiation beam therapy using linear accelerators (LINACs). Historically, radiation therapy events involving LINACs have not been uniformly reported across the country because LINACs are regulated by state radiation control programs, and reporting requirements vary among states. The Nuclear Regulatory Commission's Nuclear Material Events Database (NMED) only tracks events involving radioactive materials (RAM). Efforts to track medical events involving LINACs at a national level have begun only recently. This article highlights the importance of tracking and analyzing all medical radiation events in order to improve quality of care and patient safety. An analysis of a subset of the data collected by the NYSDOH from 2001-2009 is presented. This subset consists of only events arising from the use of LINACs in radiation therapy. There are very few publications on errors and error rates in the use of medical accelerators in radiation therapy. This analysis highlights the most common types of errors, causes and contributing factors, areas for improvement and actions taken to bring this information to the regulated community. An error rate of 0.07% per patient receiving radiation treatment is estimated using these data and the New York State Tumor Registry data for the same period. NY State Regulations governing the practice of Radiation Oncology have been revised recently to reflect the increased complexity in the delivery of therapeutic radiation. Collaboration and sharing of data such as those presented here, between federal, state and local regulators, professional organizations such as the Conference of Radiation Control Program Directors (CRCPD), American Society for Radiation Oncology (ASTRO), American Association of Physicists in Medicine (AAPM), American College of Radiology (ACR), American College of Radiation Oncology (ACRO), manufacturers of medical radiation equipment and software developers and the regulated community has begun and will contribute to improved quality of care and patient safety.
authors.affiliation: *New York State Department of Health, Bureau of Environmental Radiation Protection, Corning Tower, 12th Floor, Empire State Plaza, Albany, NY 12237.
authors.forename: Janaki
authors.initials: J
authors.lastname: Krishnamoorthy
authors.forename: Adela
authors.initials: A
authors.lastname: Salame-Alfie
authors.forename: John
authors.initials: J
authors.lastname: O'Connell
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D009313:National Health Programs; D010315:Particle Accelerators / Q000592:standards*; D061214:Patient Safety / Q000331:legislation & jurisprudence*; D011835:Radiation Protection / Q000331:legislation & jurisprudence / Q000592:standards*; D011872:Radiology Department, Hospital / Q000592:standards*; D011878:Radiotherapy / Q000009:adverse effects*; D017751:Safety Management / Q000458:organization & administration*; D013219:State Government