In early 2010 we did several columns on radiation safety issues after the NY Times publication of its eye-opening 2-part series (Bogdanich 2010a and 2010b) on the hazards of radiation (see our February 2, 2010 Patient Safety Tip of the Week “The Hazards of Radiation” and our March 2010 What’s New in the Patient Safety World column “More on Radiation Safety”). And earlier this year we highlighted some studies in a new journal, Practical Radiation Oncology, on activities related to reducing risks of radiation overdose during radiation oncology treatments (see our February 2011 What’s New in the Patient Safety World column “New Journal Highlights Safety in Radiation Oncology”).
One of the papers (Marks 2011) discussed a FMEA (failure mode and effects analysis) to identify potential sources for error and mitigate them. The Radiation Medicine Department at North Shore-Long Island Jewish Health System also did a FMEA (North Shore-Long Island Jewish Health System 2011). They mapped out all the processes involved in planning for and providing radiation treatments and broke the process down into key components. They then implemented a “no-fly” policy in which no treatment may be started until each of those key components has been signed off on. If one or more steps had not been satisfactorily completed, the treatment would be rescheduled. They educated their patients about the importance of stopping and rescheduling and most patients felt comfortable and confident with the concept. The department also found that the number of cases that had to be stopped and rescheduled dropped considerably within a month of implementation.
Do you have a “no-fly” policy?
Bogdanich W. The Radiation Boom. Radiation Offers New Cures, and Ways to Do Harm. New York Times. January 24, 2010
Bogdanich W. The Radiation Boom. As Technology Surges, Radiation Safeguards Lag.
The New York Times. January 26, 2010
Marks LB, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation oncology. Practical Radiation Oncology 2011; 1(1): 2-14
North Shore-Long Island Jewish Health System. Ensuring The Safety Of Radiation Therapy. Medical News Today. May 20, 2011