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Lessons Learned From Misadministrations and Accidents in Radiation Therapy Part I: Teletherapy


R Foster


R Foster1*, (1) UT Southwestern Medical Center, DALLAS, TX

TU-G-218-1 Tuesday 4:30:00 PM - 6:00:00 PM Room: 218

The recent publicity received by the radiation oncology community regarding misadministrations, accidents and overdoses has renewed the medical physicists’ focus on safety. However, many other accidents have preceded these. Are these recent incidents similar to older ones and could they have been prevented had the medical physics community applied the lessons learned from previous incidents? Certainly technology is more advanced, but adherence to established doctrines and recommendations from our professional societies could have prevented the majority of these accidents.

In this presentation, recent and much older accidents and misadministrations in radiation therapy that have been reported in the media will be presented. These events serve as teaching moments for the clinical physicists and opportunities to assess our own strategies and clinical programs with the goal of providing safe and reliable treatment deliveries. The recommendations and QA that have been established in the literature will be presented in concert with events that have either been near-misses or grave accidents. This presentation will focus on both conventional linac delivery and the more sophisticated treatments such as SRT and IMRT.

Learning Objectives:
1. To review and understand the causes of various external beam treatment misadministrations and accidents reported in the media.
2. To review and understand corrective and preventative actions that should be in place in order to safely administer external beam RT.
3. To review and understand the recommendation for safety by the ASTRO, ACR, and AAPM and the ABS.
4. To review and understand the ASTRO Six Point Protection Plan.


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