IAEA Training Course

PREVENTION OF ACCIDENTAL
EXPOSURE IN RADIOTHERAPY

Part 2: Case histories of

major accidental exposures in radiotherapy

IAEA
International Atomic Energy Agency
 IAEA Training Course

Module 2.10: Accident update

– some newer events
(UK, USA, France)

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International Atomic Energy Agency
 Questions

Do you think the accidents have not happened in recent

years?

Do you think well-developed centres are immune to these

accidents?

IAEA Prevention of accidental exposure in radiotherapy 3

 Overview

It should be noted that the intent is certainly not to reflect the

quoted centres in this presentation in poor light

Instead, the purpose is to draw lessons

In many cases, the centres have a quality system in place

The events are reconstructed from information in the public

domain, and might differ from actual events due to gaps in
this information.

IAEA Prevention of accidental exposure in radiotherapy 4

 Overview

Newer examples of accidents in radiotherapy from 2004 to 2007

• 1st example: Incorrect manual parameter transfer

(UK)
• 2nd example: Reversal of images (USA)
• 3rd example: Inappropriate measuring device
(France)
• 4th example: Erroneous calculation for soft
wedges (France)
• 5th example: Incorrect IMRT planning (USA)

IAEA Prevention of accidental exposure in radiotherapy 5

 IAEA Training Course

1st example: Incorrect manual

parameter transfer (UK)

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Background

• January 2006 at the Beatson

Oncology Centre (BOC) in
Glasgow, Scotland
• At the time: Radiotherapy
physics staffing levels in
Scotland less than 60% of the
recommended level The Beatson Oncology
Centre in Glasgow
• “Glasgow has problems with
recruiting physicists, as shown
by their high number of
vacancies.”

IAEA Prevention of accidental exposure in radiotherapy 7

 Background

• Treatment planning at BOC:

• 14.5 whole time equivalent
(WTE) staff were available for
between 4500 and 5000 new
treatment plans per year.
• When staffing levels were
compared with guidelines from
IPEM, it was seen that 18 WTE
staff would be the
recommended level.

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 Background

• Treatment planning at BOC:

• Planning staff members and planning procedures were
both categorized
• A to C denotes senior to junior staff
• A to E denotes simple to complex plans
• The main duties per staff category is outlined in column 4

Table from: “Report of an investigation by the Inspector appointed by the Scottish Ministers for The Ionising Radiation
(Medical Exposures) Regulations 2000”
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 Background

• Treatment planning at BOC:

• Practice prior to 2005 had been to let the treatment
planning system (TPS) calculate the Monitor Units (MU)
for 1 Gy followed by manual multiplication with the
intended dose per fraction for the correct MU-setting to
use.

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 Background

• Treatment planning at BOC:

• In May 2005, the Record and Verify (RV) system was
upgraded to be a more integrated platform.
• The centre decided to input the dose per fraction already
in the TPS, for most but not all treatment techniques.

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 What happened?

• 5th January 2006, Lisa Norris,

15 years old, started her whole
CNS treatment at BOC
• The treatment plan was
divided into head-fields and
lower and upper spine-fields
• This is considered to be a Lisa Norris

complex treatment plan,

performed about six times per
year at the BOC.
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 What happened?

• The bulk of the planning was done by

“Planner X” in Dec’05, a junior planner
• “Planner X” had not yet been
registered internally to be competent to
plan whole CNS, or to train on these
• “Planner X” got initial instructions and
the opportunity to be supervised
when creating the plan

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 What happened?

• Whole CNS plans still went

by the “old system”, where
TPS calculates MU for 1 Gy
with subsequent upscaling
for dose per fx
• A “medulla planning form”
was used, which is passed
to treatment radiographers
for final MU
calculations
Table from: “Report of an investigation by the Inspector appointed by the Scottish Ministers for The Ionising Radiation

IAEA (Medical Exposures) Regulations 2000”

Prevention of accidental exposure in radiotherapy 14
 What happened?

• HOWEVER – “Planner X”
let the TPS calculate the
MU for the full dose per fx
– not for 1 Gy as intended
• Since the dose per fx to
the head was 1.67 Gy, the
MU’s entered in the form
were 67% too high for
each of the
head-fields
Table from: “Report of an investigation by the Inspector appointed by the Scottish Ministers for The Ionising Radiation
(Medical Exposures) Regulations 2000”
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 What happened?

• This error was not found

by the more senior
planners who checked the
plan
• The radiographer on the
unit thus multiplied with
the dose per fx a second
time
• 2.92 Gy per fx
to the head
Table from: “Report of an investigation by the Inspector appointed by the Scottish Ministers for The Ionising Radiation
(Medical Exposures) Regulations 2000”
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 Discovery of accident

• “Planner X” calculated another plan of the

same kind and made the same mistake
• This time, the error was discovered by a
senior checker (1st of Feb ‘’06)
• The same day, the error in calculations for
Lisa Norris was also identified

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 Impact of accident

• The total dose to Lisa

Norris from the Right
and Left Lateral head
fields was 55.5 Gy (19 x
2.92 Gy)
• She died nine months
after the accident

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 Lessons to learn
• Ensure that all staff
• Are properly trained in safety critical procedures
• Are included in training programmes and has
supervision as necessary, and that records of training
are kept up-to-date
• Understand their responsibilities
• Include in the Quality Assurance Program
• Formal procedures for verifying the risks following the
introduction of new technologies and procedures
• Independent MU checking of ALL treatment plans
• Review staffing levels and competencies

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 References

• Unintended overexposure of patient Lisa Norris during radiotherapy

treatment at the Beatson Oncology Centre, Glasgow in January 2006.
Report of an investigation by the Inspector appointed by the Scottish
Ministers for The Ionising Radiation (Medical Exposures) Regulations
2000 (2006)

• Cancer in Scotland: Radiotherapy Activity Planning for Scotland 2011 –

2015. Report of The Radiotherapy Activity Planning Steering Group’
The Scottish Executive. Edinburgh. (2006)

• The Glasgow incident – a physicist’s reflections. W.P.M. Mayles. Clin

Oncol 19:4-7 (2007)

• Radiotherapy near misses, incidents and errors: radiotherapy incident

in Glasgow. M.V. Williams. Clin Oncol 19:1-3 (2007)

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 IAEA Training Course

2nd example: Reversal of images

(USA)

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 What happened?

• October 2007 at the Karmanos

Cancer Center (KCC) in
midtown Detroit, Michigan, USA
• At the Gamma Knife treatment
facility, a patient was set up for
MRI imaging
• Standard practice is to position The KCC in Detroit

the patient “head first”

• The patient was positioned “head
first”, but “feet first” scan
technique was chosen on the unit

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 What happened?

• The axial images were

therefore reversed left-to-right
• The physicist did not see the
mistake when importing images
into the TPS
• The error resulted in an 18 mm
shift of isocentre across the Stereotactic treatment
(image from KCC)
midline of the brain

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 Lessons to learn
• Include in the Quality Assurance Program
• Procedures for verifying left from right in safety
critical images, e.g. by using fiducial markers
• Ensure there are written protocols posted,
known and followed, for safety critical
procedures

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 References

• Gamma knife treatment to wrong side of

brain. Event Notification Report 43746.
United States Nuclear Regulatory
Commission (2007)

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 IAEA Training Course

3rd example: Inappropriate measuring

device (France)

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International Atomic Energy Agency
 Background

• Reported 2007 at Hôpital de

Rangueil in Toulouse, France
• In April 2006, the physicist in the
clinic commissioned the new
BrainLAB Novalis stereotactic
unit
• This unit can operate with The Hôpital de Rangueil
in Toulouse
microMLC’s (3 mm leaf-width)
or conical standard collimators

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 Background

• Very small fields can be

defined with the microMLC’s
• High dose to a 6 x 6 mm field is
within capability
• The TPS requires percent depth
doses, beam profiles and
relative scatter factors down to
this field size
• Care must be taken when
measuring small fields!

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 What happened?

• Different measuring devices

were used by the physicist
• A measuring device not suitable
for calibrating the smallest
microbeams was used
• “…an ionisation chamber of
inappropriate dimensions…”
according to Nuclear Safety
Authority (ASN) inspectors

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 What happened?

• The incorrect data was

entered into the TPS
• All patients treated with micro
MLC were planned based on
this incorrect data
• Patients treated with conical
collimator were not affected

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 Discovery of accident

• BrainLAB discovered that the measurement

files did not match up with those at other
comparable centres, during a worldwide
intercomparison study
• It should be noted that the company does
not validate or hold responsibility for local
measurements or implementation

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 Impact of accident

• Treatment based on the incorrect data went

on for a year (Apr´06 – Apr´07)
• All patients treated with microMLC were
affected (145 of 172 stereotactic patients)
• The dosimetric impact was evaluated as
small in most cases, with 6 patients
identified for whom over 5% of the volume of
healthy organs may have been affected by
dose exceeding limits
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 Lessons to learn
• Ensure that staff
• Understand the properties and limitations of the
equipment they are using
• Include in the Quality Assurance Program
• Intercomparison with other hospitals, i.e.
independent check of new equipment by
independent group (using independent
equipment) before equipment is clinically used

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 References

• Report concerning the radiotherapy incident

at the university hospital centre (CHU) in
Toulouse – Rangueil Hospital. ASN –
Autorité de Sûreté Nucléaire (2007)

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 IAEA Training Course

4th example: Erroneous calculation

for soft wedges (France)

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 Background

• In May 2004 at Centre

Hospitalier Jean Monnet in
Epinal, France
• …it was decided to change from
static (hard) wedges to dynamic
(soft) wedges for prostate
cancer patients The Jean Monnet Hospital
in Epinal
• In a country of few Medical
Physicists (MP), this facility had
a single MP who was also on
call in another clinic

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 Background

• In preparation for the change in treatment

technique, two operators (treatment
planners?) were given two brief demo’s
• The operators did not have any operating
manual in their native language

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 Background

• When the soft wedges were introduced:

• The independent MU check in use could not be
used anymore (unless modified)
• The diodes used for independent dose check
could not be correctly interpreted anymore

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 What happened?

• Treatment planning with soft

wedges started 15
• Not all the treatment planners did 30

understand the interface to the 45

planning system
DW

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 What happened?

• Treatment planning with soft

15
wedges started
v 30
• Not all the treatment planners did
45
understand the interface to the
planning system DW

• Some selected the planning for

mechanical wedge when intending
dynamic wedge

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 What happened?

• Treatment planning with soft

wedges started 15

• Not all the treatment planners did 30

45
understand the interface to the
planning system v DW

• Some selected the planning for

mechanical wedge when intending
dynamic wedge
• Instead they should have selected
Dynamic Wedge…

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 What happened?

• Treatment planning with soft

wedges started 15

• Not all the treatment planners did 30

45
understand the interface to the
planning system v DW

• Some selected the planning for

15
mechanical wedge when intending
30
dynamic wedge
• Instead they should have selected 45

Dynamic Wedge…
• …which would have let the correct
planning tool appear
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 What happened?

• When planning was finished and

the isodose distribution approved
• …the parameters were manually
transferred to the treatment unit
• Manually transferred MU’s would
have been calculated for
mechanical wedges and would be
much greater than what is needed
for giving the same dose with
dynamic wedges

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 Discovery of accident

• Details not clear, BUT: it might have been

when MU check software was replaced and
updated to be able to handle independent
checking of dynamic wedges.

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 Impact of accident

• Treatment based on incorrect MU’s went on

for over a year (6 May 2004 – 1 Aug 2005)
• At least 23 patients received overdose (20%
or more than intended dose)
• Between September 2005 and September
2006, four patients died. At least ten patients
show severe radiation complications
(symptoms such as intense pain, discharges
and fistulas)
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 Information following accident

• 15 Sep 2005, two doctors from the clinic passed

on information that went to the Regional Dept. of
Health and Social Security (DDASS)
• 5 Oct 2005 a meeting was held at DDASS.
Decisions were not documented or uniformly
interpreted.
• National authorities in charge were not informed at
this stage, but only a full year after the accident
(July 2006)

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 Information following accident

• 7 patients were informed during the last

quarter of 2005.
• 16 other patients were (wrongly) considered
no to be affected. Of these …
• … 3 were informed by another doctor than their radiotherapist
• … 1 learnt from a third party person
• … 1 learnt from the press
• … 1 learnt by overhearing a doctor speaking to a colleague
• … 4 were informed by management 2 days before press release
• … 1 died before being informed

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 Lessons to learn
• Ensure that staff
• Understand the properties and limitations of the equipment they are
using
• Are properly trained in safety critical procedures
• Include in the Quality Assurance Program
• Formal procedures for verifying new technologies and procedures before
implementation
• Independent MU checking of ALL treatment plans
• In vivo dosimetry
• Make sure the clinic has a system in place for
• Investigation and reporting of accidents
• Patient management and follow up, including communication to patients
• Instructions should be in a language that is understood

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 References

• Summary of ASN report n° 2006 ENSTR 019 - IGAS n° RM 2007-015P

on the Epinal radiotherapy accident. G. Wack, F. Lalande, M.D.
Seligman (2007)

• Accident de radiothérapie à Épinal. P.J. Compte. Société Française de

Physique Médicale (2006)

• Lessons from Epinal. D. Ash. Clin Oncol 19:614-615 (2007)

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 Postscript to accident in Epinal

• Going through the records, two further

episodes were reported subsequently
• Reported in Feb 2007:
• In the time period 2001-2006, portal imaging was used
repeatedly without taking into account the added dose
(estimated to have been +8% of total) for 412 patients under
medical survey
• Reported in July 2007:
• In the time period 1989-2000, use of an in-
house TPS not updated after change in
treatment technique, might have led to 300
patients receiving up to 7% added dose.

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 IAEA Training Course

5th example: Incorrect IMRT planning

(USA)

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International Atomic Energy Agency
 Background
• March 2005, somewhere in the state of New York,
USA
• A patient is due to be treated with IMRT for head and
neck cancer (oropharynx)

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 What happened?
• March 4 – 7, 2005
• An IMRT plan is prepared: “1 Oropharyn”. A verification
plan is created in the TPS and measurements by Portal
Dosimetry (with EPID) confirms correctness.

Example of an EPID (Electronic Portal Imaging Device) (Picture: P.Munro)

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 What happened?
• March 8, 2005
• The patient begins treatment with the plan “1 Oropharyn”.
This treatment is delivered correctly.

“Model view” of treatment plan (Picture: VMS)

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 What happened?
• March 9-11, 2005
• Fractions #2, 3 and 4 are also delivered correctly.
Verification images for the kV imaging system are created
and added to the plan, now called “1A Oropharyn”.

“Model view” of treatment plan (Picture: VMS)

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 What happened?
• March 11, 2005
• The physician reviews the case and wants a modified
dose distribution (reducing dose to teeth) “1A Oropharyn”
is copied and saved to the DB as “1B Oropharyn”.

“Model view” of treatment plan (Picture: VMS)

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 What happened?
• March 14, 2005
• Re-optimization work on “1B Oropharyn” starts on
workstation 2 (WS2).
• Fractionation is changed. Existing fluences are deleted
and re-optimized. New optimal fluences are saved to DB.
• Final calculations are started, where MLC motion control
points for IMRT are generated. Normal completion.

Multi Leaf Collimator

(MLC)

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 What happened?
• March 14, 2005, 11 a.m.
• “Save all” is started. All new and modified data should be
saved to the DB.
• In this process, data is sent to a holding area on the
server, and not saved permanently until ALL data
elements have been received.
• In this case, data to be saved included: (1) actual fluence
data, (2) a DRR and (3) the MLC control points

A Digitally Reconstructed
Radiograph (DRR) of the
patient

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 What happened?
• March 14, 2005, 11 a.m.
• The actual fluence data is saved normally.
• Next in line is the DRR. The “Save all” process continues
with this, but is not completed.
• Saving of MLC control point data would be after the
DRR, but will not start because of the above.

A Digitally Reconstructed
Radiograph (DRR) of the
patient

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 What happened?
• March 14, 2005, 11 a.m.
• An error message is displayed.
• The user presses “Yes”, which begins a second,
separate, save transaction.
• MLC control point data is moved to the holding area.

The transaction error message displayed

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 What happened?
• March 14, 2005, 11.a.m.
• The DRR is, however, still locked into the faulty first
attempt to save.
• This means the second save won’t be able to complete.
• The software would have appeared to be frozen.

The frozen state of the second “Save All” progress indication

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 What happened?
• March 14, 2005, 11.a.m.
• The user then terminated the TPS software manually,
probably with Ctrl-Alt-Del or Windows Task Manager
• At manual termination, the DB performs a “roll-back” to
return the data in the holding area to its last known valid
state
• The treatment plan now contains (1) actual fluence data;
(2) not the full DRR; (3) no MLC control point data

Ctrl-Alt-Del

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 What happened?
• March 14, 2005, 11.a.m.
• Within 12 s, another workstation, WS1, is used to open
the patients plan. The planner would have seen this:

Valid fluences were already

saved. Calculation of dose
distribution is now done by the
planner and saved. MLC control
point data is not required for
calculation of dose distribution.

Sagittal view of patient, with fields and

dose distribution

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 What happened?
• March 14, 2005, 11.a.m.
• No control point data is included in the plan.

The sagittal view should have looked like the one to the right, with MLCs

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 What happened?
• March 14, 2005, 11 a.m.
• No verification plan is generated or used for checking
purposes, prior to treatment (should be done according
to clinics QA programme)
• The plan is subsequently prepared for treatment
(treatment scheduling, image scheduling, etc) – after
several computer crashes.
• It is also approved by a physician
• According to QA programme, a second physicist should
then have reviewed the plan, including an overview of
the irradiated area outline, and the MLC shape used.

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 What happened?
• Would have been seen on verification:

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 What happened?
• Should have been seen on verification:

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 What happened?
• March 14, 2005, 1 p.m.
• The patient is treated. The console screen would have
indicated that MLC is not being used during treatment:

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 What happened?
• March 14, 2005, 1 p.m.
• Expected display:

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 Discovery of accident
• March 15-16, 2005
• The patient is treated without MLCs for three fractions
• On March 16, a verification plan is created and run on
the treatment machine. The operator notices the
absence of MLCs.
• A second verification plan is created and run with the
same result.
• The patient plan is loaded and run, with the same result.

Impact of accident
• The patient received 13 Gy per fraction for
three fractions, i.e. 39 Gy in 3 fractions
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 Lessons to learn
• Do what you should be doing according to your QA
program – the error could have been found through
verification plan (normal QA procedure at the
facility) or independent review

• Be alert when computer crashes or freezes, when

the data worked on is safety critical

• Work with awareness at treatment unit, and keep an

eye out for unexpected behaviour of machine

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 References

• [Treatment Facility] Incident Evaluation Summary, CP-2005-049

VMS. 1-12 (2005)

• ORH Information Notice 2005-01. Office of Radiological Health,

NYC Department of Health and Mental Hygien (2005)

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 Questions

Do you think the accidents have not happened in recent

years? ANSWER: NO! If YES, then think again!

Do you think well-developed centres are immune to these

accidents? ANSWER: NO! If YES, then think again!

IAEA Prevention of accidental exposure in radiotherapy 73