Radiation Oncology Report

The year 2010 was a watershed moment in the field of radiation oncology, due to articles written by Walt Bogdanich in the New York Times. These articles critiqued leadership, radiation dose, and patient safety, and accused the community of using unsafe practices (Washington & Leaver, 2016). While there had been previous accidents which injured and killed patients during the 1980s, those few accidents were attributed to equipment faults, as computer equipment was merged with treatment delivery equipment. The deaths that the Bogdanich articles referred to could not be written off as faults of equipment or devices, but rather due to unsafe practices which were not addressed. The American Society for Radiation Oncology (ASTRO) and the ASRT,
along with associations of medical physicists and administrators, issued statements addressing the New York Times articles, and provided testimony before the U. S. Congress after being summoned for a congressional hearing. ASTRO published the document ‘Safety is no Accident: A Framework for Quality Radiation Oncology and Care’ (2012). This document was developed and endorsed by 11 organizations involved in radiation oncology. The document sets a high bar, acknowledging that in the time of shrinking budgets, the criteria set forth may be difficult to meet, but that no center should fall short, and although difficult, the task of transformation is not impossible (ASTRO, 2012). In addition to the document, ASTRO has begun a new accreditation process, to improve accountability at cancer centers. This includes sixteen standards, and of those, the seventh is the development of a ‘culture of safety’. Washington and Leaver (2016) note that this is a major shift in previous thinking, in which physicians and physicists were the overseers of quality and safety indicators.
The implementation of a culture of safety empowers and demands that all employees are engaged, and work in an open environment in which they may speak up without fear of reprisal. It has been recognized that the frontline staff are the employees most likely to recognized the shortcomings in workflow and processes which limit their effectiveness to provide the best care for patients under
treatment. The authors of Safety is no Accident, and the Washington and Leaver textbook note that the change that is required will be difficult, as it requires an ongoing commitment, and constant effort. However, the increasingly complex delivery of treatment demands the coordinated effort by all team members (ASTRO, 2012). This was recognized in England also, as a collaboration of professional organizations there published a similar document called Toward Safer Radiotherapy, in 2008. The transformation that needs to occur may be the most critical issue facing the radiation therapy community.
If centers are successful, the result should be a lower probability of a mistreatment of a patient, and improved morale when staff members feel empowered and find that their voices will be heard. The concern that I have for this issue is the chasm between the presentations made to Congress and printed in response documents, versus the lack of implementation at treatment centers of the principles and standards which those documents suggests are necessary, using strong and unapologetic language. An example was shared with me from this past weekend, in which an on-call therapist responded to the treatment center for an emergency case. Although the standard Monday through Friday is for two therapists to provide treatment per machine, this is not the case during the weekend, at most centers. The cases which receive treatment on Saturday and Sunday are emergent in nature, and often a single therapist provides the treatment, although management often states that there will be two therapists per machine, at least during the work week. It is not hard to imagine the outcome of a court case in which the standard of care is meet during the week, but a lower standard is provided on the weekend, during a more difficult treatment situation, possibly involving a patient whose pain is not controlled, or perhaps a patient suffering partial paralysis due to
disease. I am hopeful that transformation will happen, even if the pace is slower than I would prefer, and that employees are provided the tools to build a culture of safety.