A Short Summary of

Accidents Involving Radiation

J. Francisco Aguirre M.S., DABR

Consultant in Medical Physics
 Types of Accidents
Involving Radiation
Accidents in nuclear reactors
Accidents in research nuclear reactors
Accidents in miliyary nuclear reactors
Criticality accidents
Accelerator accidents
Dispersion of radioactive material
Internal exposure to radioisotopes
Accidents with an irradiator
Medical accidents in radiotherapy
Medical accidents in radiodiagnostic
Orphan sources
Dispersion of orphan sources
Types of Accidents
Involving Radiation
 Accident Statistics
1886 - 2009
• 391 documented events in total

• 135 (35%) related to medical or industrial

radiography, radiotherapy, lost sources,
theft, suicide or homicide, isotope
ingestión or dispersion

• 45 countries

• 32 cases (8.2%) in radiotherapy

• 181 deaths

• 1176 injured
 Accident Statistics
1886 - 2009
RUSSIA 193
USA 51
CHINA 21
ENGLAND 12
WEST GERMANY 11
ARGENTINA 11
EAST GERMANY 10
FRANCE 9
INDIA 9
JAPAN 5
CHECKSLOVAKIA 4
 Accidents Involving
Medical and Industrial Applications
Medical and industrial Radiography 49
Radiotherapy 32
Lost sources 23
Suicide, Homicide, criminal intent 19
Theft 8
Dispersion 2
Isotope Ingestion 2

Radiotherapy Accidents in the USA 17

Deaths 22
Physical damage 100
 Accidents in the United States

• 52 accidents of all types

• 14% of all the accidents in the world

• 17 accidents in radiotherapy (33%)

• 22 deaths

• 100 injured
 Classification of Accidents

Of inmediate identification
Easily manageable and of limited number of victims (H igh
or medium dose rate medical or industrial
Difficult management (Brasil, Mexican border, Perú)
Catastrophic (Chernobyl,
Of delayed identification
Mexico DF (stolen cobalt source), Italy (irradiator) Argelia,
Morocco (HDR Ir) El Salvador (Irradiator) Cairo (found
industrial source), France and Vietnam (wrong repair or
use of linear accelerator)
Criminal action
Sources used as weapons (El Salvador, USA, Francia,
Londres)
Accidents kept secret
Types of Accidents

 Minor
 Major
 Catastrophic
 Types of Accidents

 One or a few victims

 Many people in a limited
area
 Many people over a large
area
Terminology for Medical Errors

• Incidents
• Events
• Errors
• Misadministrations
• Unusual ocurrences
• Discrepancies
• Adverse Events
 Definitions from the
World Health Organization
Incident: An event or circumstance that could
have resulted or resulted as unnnecessary
damage to a patient

Error: The failure to complete a planned action

according to its intended purpose or the
implementation of an incorrect plan through the
execution of an incorrect action (error of
commission) or the failure to execute the
correct action either during the planning phase
or during its execution (error of omision)
 Avoidance of Treatment Errors
Error
“The failure of planned action to be
completed as intended (i.e., error of
execution) or the use of a wrong plan to
achieve an aim (i.e., error of planning).”
Institute of Medicine. To Err is Human: Building a Safer Health System, 2000.

• Note: Random and systematic “errors”

should be called “uncertainties”
 Accidents in Radiotherapy
Generally speaking, treatment of a disease with
radiotherapy represents a twofold risk for the patient:

• Firstly, and primarily, there is the potential failure to

control the initial disease, which, when it is malignant, is
eventually lethal to the patient;
• Secondly, there is the risk to normal tissue from
increased exposure to radiation.

Thus in radiotherapy an accident or a misadministration

is significant if it results in either an underdose or an
overdose, whereas in conventional radiation protection
only overdoses are generally of concern.
 IAEA: Categories of Errors
Categories Number of
errors

Radiation measurement systems 5

External beam:
Machine commissioning & calibration 15
External beam therapy:
Treatment planning, patient setup and treatment 26
Decommissioning of teletherapy equipment 2
Mechanical and electrical malfunctions 4
Brachytherapy:
Low dose rate sources and applicators 29
Brachytherapy: High dose rate 3
Unsealed sources 8
92
 Medical Errors - General

US annual errors
44K-98K people die from medical errors
More than motor vehicle accidents, breast cancer or
AIDS
Total annual cost $37.6 to $50 billion
Most common types
Technical (44%)
Diagnosis (17%)
Failure to prevent injury (12%)
Use of drugs (10%)

Institute of Medicine. To Err is Human: Building a Safer Health System, 2000.

 “Keep the Patients Safe”
“Human error per se does not usually kill patients, but
human error in a weak system can injure or even
kill. A weak safety culture, weak operational
practices, weaknesses in the presence of protocols
and training, weaknesses in communication and
serious weaknesses in the packaging and design of
drugs. In short, comprehensive systems weaknesses
greatly increase the risk of harm coming to a patient.”

Sir Liam Donaldson, Chief Medical Officer, England, March 2003

http://www.iqa.org/publication/c4-1-78.shtml
Errors in RT: Contributing Factors
• Insufficient education
• Lack of procedures/protocols as part of
comprehensive QA program
• Lack of supervision of compliance with QA
program
• Lack of training for “unusual” situations
• Lack of a “safety culture”
 Sources of Uncertainties
During Treatment

Machine performance
Determination of dose from radiation
Patient specific data for treatment planning
Calculation of radiation dose to the patient
Transfer of data from the treatment plan to the
treatment machine
Day to day variations in the treatment (machine/patient
motion/set up)
 Accidert vs Incident

Accident: any non planned during which it is

very possible that the established dose limits
may have been exceeded

Incident: any non planned event during which it

is very possible that the nolmal dosis may have
been exceeded

In both cases the administered dose does not

agree with that planned.

In many cases accidents cause injuries or

death
 Classification of Incidents

Recordable: any incident that deviates from the

desired doses must be investigated and
reported internally

Reportable: any incident that is over the in

agreement with established criteria
Incidents per Stage of the Treatment
• Decision to treat and prescription

• Positioning and inmobilization

• Simulation, imaging and volume

delineation

• Comissioning

• Treatment planning

• Transfer of information

• Patient positioning

• Treatment delivery
 ‘Chain’ of 3DCRT/IMRT 3D Imaging
Process

Target
Volume and
OAR
Dose
Computation
Beam Selection
Modeling
Biology

Collimation Design

Verifying Dose Evaluation

Patient
Positioning Steve Webb, 1992
 Incidents During Evaluation

• Incorrect Identificationof the patient

• Incorrect patient record

• Wrong diagnosis (staging, spread, …)

• Inadequate records
 Incidents During the
Decision to Treat

• Lack of coordination with the other

specialties

• Lack of identification of the physician in

charge

• Failure to transfer the patient to the correct

pysician and at the right ime

• Wrong diagnosis, inadequate protocol

• Lack of multidisciplinary discussion

 Incidents During the
Decision to Treat
• Incorrect identification of the patient

• Lack of coordination with other modalities

• Missing components of the prescription

• Inapropriate authorization of the

incomplete prescription

• Alterations of the prescription

 Incidents During Inmobilization

• The patient is unable to comply with the

inmobilization requirements

• Incorrect positioning

• Different positioning for different imaging

modalities

• Incorrect inmobilizatin position

• Wrong inmobilization device

• Wrong transfer of the inmobilization

instructions
 Incidents During Imaging or
Simulation (1)
• Incorrect identification of the patient

• Wrong localization of reference points

• Wrong volumen definition

• Incorrect tumor margins

• Incorrect contouring of the organs at risk

• Lack of alignment of the light fields or the

cross hairs

• Inability to identify the isocenter

 Incidents During Imaging or
Simulation (2)
• Incorrect identification of the patient

• Wrong localization of reference points

• Wrong volumen definition

• Incorrect tumor margins

• Incorrect contouring of the organs at risk

• Lack of alignment of the light fields or the

cross hairs

• Inability to identify the isocenter

 Incidents During Planning
• Wrong calibration

• Incorrect dosimetry data

• Incorrect data (decay, constant tables)

• Inadequate use of the software,wrong

monitor unit calculation

• Lack of independent verification

• Incorrect plan (modality, energy, field size,

normalización, prescription point, use of
bolus, %DD, etc)
 Incidents During the
Transfer of Information (1)
• Incorrect identificación of the patient

• Manual data entry

• Design of an incompatible chart

• Unreadable handwriting for manual transfers

• No independent verification

• Incorrect data entry in the record and verify

system

• Ambiguous or badly written prescripción

 Incidents During the
Transfer of Information (1)
• Incorrect identificación of the patient

• Manual data entry

• Design of an incompatible chart

• Unreadable handwriting for manual transfers

• No independent verification

• Incorrect data entry in the record and verify

system

• Ambiguous or badly written prescripción

 Incidents During the
Transfer of Information (2)

• Proceed with a plan without approval

• Failure to communicate plan changes

• Error in the monitor units, accessories,

wedges
 Incidents Positioning the
Patient
• Incorrect patient identification

• Failure to evaluate the medical condition of

the patient

• Wrong positioning, wrong inmobilization

device, wrong side of the body, wrong
isocenter

• Treatment unnecessarily complex

• The patient was moving during treatment

Incidents Delivering Treatment (1)

• Undetected equipment failure

• Equipment operated in physics mode instead

of clinic mode

• Incorrect identification of the patient

• Poor management of the patient

• Incorrect field or orientation

Incidents Delivering Treatment (2)

• Excessive or not enough fractions

• Inadequate verification of the treatment

parameters

• Warm up procedures not followed

 Incidents at Record and Verify
• Incorrect identification of the patient

• Incorrect use or lack of portal images

• Wrong interpretation of the portal images

• Failure to monitor results

• Lack of patient evaluation

• Absent or deficient record review

• Undetected errors
 Factors Contributing to Errors in
Radiotherapy

Insuficient education
Lack of protocols/procedures as part of a QA
program
Lack of supervision to follow the QA program
Lack of training on unusual situations
Abscense of a “safety culture”
The Important Laws of Medical
Physics

Inverse square
Decay
Brag-Gray
Probabilities
Murphy
Anything that can go wrong
will go wrong

If something cannot go
wrong, it will go wrong
anyway

Murphy
If everything seems to
be going well

you do not know what

is going on

Murphy?
 Things to Have in Mind

 Accidents happen

 They happen even in the

best of circumstances

 They happen to the “best of

the best”
 The Bottom Line…

… is not whether an accident will happen but rather

 How soon it is discovered

 How it is corrected

 How it is prevented from

happening again

Establish a culture of prevention

 Who is Responsible

 Radiation oncologists
 Medical physicists
 Radiotherapy technologists
(therapists)
 Radiation protectionofficers
(local and national)
 Hospital Director, Service
Chief, Administrator
 The Multidisciplinary Team
Radiotherapy is a Radiation
multidisciplinary process. Oncologists

Medical
Responsibilities are shared Physicists Dosimetrist
s
between the different Radiotherapy
Process
disciplines and must be
clearly defined. Therapists Engineers

Others

 Each group has an important part in the output of the

entire process, and their overall roles, as well as their
specific quality assurance roles, are interdependent,
requiring close cooperation..
 The Worrying Signs

 Our staff is the best trained and

experienced, we do not make
mistakes
 If there were problems with these
units the manufacturer would not sell
them
 There is no reason to worry, we have
worked like this for 20 years with no
problems
 The Worrying Signs

 We have our own techniques and do not care

about what others say
 We paid $3 million dollars for this equipmen, how
can it make mistakes
 We have everything computerized, and therefore
error free
 I have been in this field for many years, I do not
make mistakes
 It is not allowed for medical physicists or
radiotherapy technologists to challenge or
question a physician plan
Thank You