Patient safety symposium draws crowds at AAPM

By Tami Freeman, Medicalphysicsweb editor

July 22, 2010 -- PHILADELPHIA - Patient safety in radiation therapy and diagnostic imaging has always been an important concern for the medical physics community. At the American Association of Physicists in Medicine (AAPM) annual meeting taking place this week, a special symposium examined the issues surrounding patient safety and what's being done to improve it.

The meeting kicked off with a talk by Walt Bogdanich, investigative journalist at the New York Times. Bogdanich is the author of a series of articles published earlier this year, which detailed a raft of irradiation accidents and highlighted the inadequacies of current error reporting procedures.

Bogdanich told a crowded auditorium that he was driven to put the articles together upon the realization that that he hadn't understood how some diagnostic imaging scans involved ionizing radiation. And if he, an investigative reporter focusing on health issues, didn't appreciate the details of the radiation involved in such tests, then most of the general public certainly didn't.

He even wondered whether the doctors really understood, citing a case in which patients at one medical center continually received too high a dose in CT scans. "How do you explain the fact that for 18 months or more, each patient was over-irradiated?" he asked, noting that the patients had all exhibited similar patterns of hair loss. "I don't know why it took so long to make the link between that test and their same symptoms."

Bogdanich said that when performing research for his articles, many of the doctors and hospitals that he contacted did not return his calls. "It took me nine months to extract data from the New York state government. It shouldn't have taken that long," he said. "However, all the medical physicists returned my calls, and were open and polite." He concluded his talk by inviting any medical physicists in the audience with problems or gripes to contact him.

In the ensuing and unsurprisingly popular question and answer session, one delegate asked Bogdanich how best to reassure patients worried about receiving diagnostic irradiation having read articles such as his in the press. "It's not a bad thing that patients are frightened," Bogdanich replied. "It's a small price to pay for education and getting patients asking questions that they didn't ask before. It's your job to answer them."

Addressing the problem

With the awareness of patient safety well and truly raised, what's the medical physics community doing to address these very valid concerns? The symposium's second speaker, William Hendee, PhD, editor of Medical Physics and distinguished professor of radiology, radiation oncology, biophysics, and community and public health at the Medical College of Wisconsin in Milwaukee, discussed one of the AAPM's recent efforts in this area: the "Safety in Radiation Therapy" conference, held last month in Miami.

The summit, attended by around 400 people, almost half of whom were medical physicists, yielded several strategies aimed at improving the safety of patients undergoing radiation therapy. "The conclusions and recommendations that came out of that meeting will be important to all of us," said Hendee.

One of the recommendations, for example, is the requirement to develop improved early warning systems. As a process performed by humans, radiotherapy is inherently subject to human error. Errors will inevitably occur, thus it's imperative to build fault-tolerant systems that spot these before they reach the patient, Hendee explained.

Further important factors include adherence to a culture of safety, zero tolerance of shortcuts, top-down safety enforcement, empowerment of all staff to stop procedures, and staff only operating within their own scope of practice. "There's a need to return control of the treatment process to those who are responsible at the point of care," said Hendee.

Other recommendations that emerged included sticking to recommended staff levels, employing timeouts and checklists, and working "as safe as reasonably achievable." Vendors must address users' concerns intelligibly, and team commitment is vital. "We need a covenant that we'll do everything we can to ensure the safety of patients," Hendee concluded. "The bottom line is that safety is everyone's responsibility."

AAPM president Michael Herman, PhD, professor of radiologic physics at Mayo Clinic in Rochester, MN, described some of the AAPM's other initiatives aimed at improving patient safety. One example is the AAPM's creation of reports on themes including quality and safety in medical imaging and radiotherapy. Another is the society's production of letters and statements on key issues, both for government and for the public. Herman also noted that since 2005, the AAPM annual meeting has been incorporating symposia on medical errors.

Herman explained that the AAPM is focusing on four main objectives in this area: recognizing qualifications, accreditation of practice, developing a system for event reporting, and improving manufacturing and approval processes. He also described a radiotherapy task force set up by AAPM, the American College of Radiology (ACR), and the American Society for Radiation Oncology (ASTRO). "One big thing coming out of this is a white paper about intensity-modulated, high-dose rate, stereotactic body and image-guided radiation therapies, and how you can do safe, high-quality versions of each of these," he said.

Work is ongoing and that there's no quick fix to improving safety, Herman emphasized. "We all must continue to be vigilant and continue to work together to develop safer, more effective use of radiation in medicine," he concluded.

International initiatives

The symposium's final speaker was Ola Holmberg, PhD, from the Radiation Protection of Patients Unit of the International Atomic Energy Association (IAEA) in Vienna, Austria, who discussed the IAEA's work on radiation accident prevention. Holmberg started by pointing out some of the fundamental issues that need to be considered. "This is a massive global activity, the overall benefits can be huge, but you always have to keep a balance," he said, noting that individual risks vary greatly and that "medical use of ionizing radiation is an inhomogeneous and rapidly developing activity."

The IAEA's response to these concerns is its International Action Plan for radiological protection of patients. The plan provides standards and guidance on specific safety issues, training and technical assistance, as well as facilitating knowledge exchange and building awareness.

"An important part of what we're doing is educating and training on radiation protection of patients," said Holmberg. This includes CD- and Internet-based resources, as well as training courses. The IAEA is also currently developing the SAFRON (safety in radiation oncology) tool to enable incident reporting and improve learning from incidents and near incidents.

"The use of radiation in medicine has brought tremendous benefits to mankind," said Holmberg. "But using radiation in medicine has associated risks; we have to remain focused on protecting the patients."

By Tami Freeman
Medicalphysicsweb editor
July 22, 2010

FDA schedules meeting on RT error reduction, May 10, 2010

Boost RT training to maintain safety standards, speakers tell FDA, April 1, 2010

FDA hearings rise above medical radiation rhetoric, March 31, 2010

Second NYTimes article highlights radiation therapy errors, January 29, 2010

NY Times article details radiation therapy errors, January 26, 2010

© IOP Publishing Limited. Republished with permission from medicalphysicsweb, a community Web site covering fundamental research and emerging technologies in medical imaging and radiation therapy.


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