Systematic review

An international review of patient safety measures in radiotherapy practice

Jesmin Shaq
a,
*
, Michael Barton
a
, Douglas Noble
b
, Claire Lemer
b
, Liam J. Donaldson
b
a
The Collaboration for Cancer Outcomes Research and Evaluation, University of New South Wales, Sydney, Australia
b
WHO World Alliance for Patient Safety, Avenue Appia 20, Geneva, Switzerland
a r t i c l e i n f o
Article history:
Received 8 October 2008
Received in revised form 4 March 2009
Accepted 4 March 2009
Available online 22 April 2009
Keywords:
Patient safety
Radiation protection
Radiotherapy accident/s
Radiotherapy error/s
Radiotherapy incident/s
Quality assurance
a b s t r a c t
Errors from radiotherapy machine or software malfunction usually are well documented as they affect
hundreds of patients, whereas random errors affecting individual patients are more difcult to be discov-
ered and prevented. Although major clinical radiotherapy incidents have been reported, many more have
remained unrecognised or have not been reported. The literature in this eld is limited as it is mostly
published as a result of investigation of major errors. We present a review of radiotherapy incidents inter-
nationally with the aim of identifying the domains where most errors occur through extensive review
and synthesis of published reports, unpublished Grey literature and departmental incident data. Our
review of radiotherapy-related events in the last three decades (19762007) identied more than seven
thousand (N = 7741) incidents and near misses. Three thousand one hundred and twenty-ve incidents
reported patient harm of variable intensity ranging from underdose increasing the risk of recurrence,
to overdose causing toxicity, and even death for 1% (N = 38); 4616 events were near misses with no rec-
ognisable patient harm. Based on our review, a radiotherapy risk prole has been published by the WHO
World Alliance for Patient Safety that highlights the role of communication, training and strict adherence
to guidelines/protocols in improving the safety of radiotherapy process.
2009 World Health Organization. Published by Elsevier Ireland Ltd. All rights reserved. Radiotherapy
and Oncology 92 (2009) 1521
Introduction
Radiotherapy treatment
Radiotherapy is one of the major treatment options in cancer
management. According to the best available evidence [2], 52% of
patients should receive radiotherapy at least once during the treat-
ment of their cancer. Together with other modalities such as sur-
gery and chemotherapy radiotherapy plays an important role in
the treatment of 40% of those patients who are cured of their can-
cer [3]. Radiotherapy is also a highly effective treatment option for
palliation and symptom control in cases of advanced or recurrent
cancer. The process of radiotherapy is complex and involves under-
standing of the principles of medical physics, radiobiology, radia-
tion safety, dosimetry, radiotherapy planning, simulation and
interaction of radiation therapy with other treatment modalities.
The main health professionals involved in the delivery of radiation
treatment are the radiation oncologists (RO), radiation therapists
(RT) and medical physicists (MP). Each of these disciplines works
through an integrated process to plan and deliver radiotherapy to
patients. The sequential stages of the radiotherapy process of care
(Fig. 1) were agreed by the Expert Committee of WHO World Alli-
ance for Patient Safety [1].
Errors in radiotherapy treatment
Accidental exposures to radiotherapy may result from an acci-
dent with a radiation source or from an event or a sequence of
events including equipment failures and operating errors [4]. Elab-
orate quality assurance (QA) protocols have been issued by a num-
ber of international and regional organisations in order to reduce
the likelihood of accidents and errors occurring, and to increase
the probability so that the errors will be recognized and rectied
quickly if they do occur [513]. Still the potential for the errors
in radiotherapy is high as it involves highly technical measure-
ments and calculations of different radiation doses to many differ-
ent parts of the body. Treatment is delivered in multiple daily
doses and patient set-up must be accurate and reproducible. Mod-
ern radiotherapy departments are multi-system-dependent envi-
ronments that rely heavily on transfer of data between patient,
machine and processing systems.
Over the last decade, the rapid development of new technology
has signicantly changed the way in which radiotherapy is
planned and delivered. Three-dimensional computed tomography
(CT)-based planning, multi-leaf collimation (MLC), improved
0167-8140/$ - see front matter 2009 World Health Organization. Published by Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.radonc.2009.03.007
* Corresponding author. Address: The Collaboration for Cancer Outcomes,
Research and Evaluation (CCORE), South Western Clinical School, University of
New South Wales, Liverpool Health Service, Locked Bag 7103, Liverpool BC, NSW
1871, Australia.
E-mail address: Jesmin.Shaq@sswahs.nsw.gov.au (J. Shaq).
Radiotherapy and Oncology 92 (2009) 1521
Contents lists available at ScienceDirect
Radiotherapy and Oncology
j our nal homepage: www. t hegr eenj our nal . com
immobilization, and more sophisticated planning software now
permit complex treatment plans to be developed for many patients
[14]. The increased complexity of planning and treatment and ra-
pid adoption of newtechnologies in the setting of increased patient
volume may thus create an environment with more potential for
treatment mishaps to occur. Especially, in the low and middle in-
come countries there may be old systems with less interconnectiv-
ity and fewer trained QA personnel. In addition, technologies
intended to reduce the risk of treatment inaccuracy might para-
doxically act as a new source of error [15].
Research on radiotherapy safety focuses on analyses of adverse
events and near misses [16,17] as these might lead to the identi-
cation of latent problems and weak links within a system that lie
dormant for some time and then combine with a local trigger to
create an incident [18]. The reporting of near misses has been iden-
tied as a valuable tool in preventing serious incidents in the non-
medical domain [19]. Although detailed reports of some major
clinical radiation adverse events in the last 30 years [20,21] have
been published, it is likely that many more have occurred but
either went unrecognised or failed to be reported to the regulatory
authorities or were not published in the literature [13]. Errors in
software or treatment machine calibration do affect hundreds of
patients and usually are well documented [13,22]. Random errors
may affect individual patients and are more difcult to be discov-
ered and prevented.
Presented below are a collation and synthesis of evidence on
radiation incidents and the recommended safety measures. Both
published literature and unpublished data sources have been re-
viewed. The areas of the highest risk in the process of care for
radiotherapy have been identied. The risk issues require further
attention, especially those not related to equipment and system
failure and modiable through competency-based training of staff
and changes in work practice culture in radiotherapy departments.
Aim
Our aim was to conduct an evidence-based review of current
practice of patient safety measures in radiotherapy treatment facil-
ities including an analysis of the previous incidents in radiotherapy
delivery and identication of high risk areas through elaborate
search of published literature and unpublished gray literature.
Materials and methods
Search strategy and selection criteria
The terminology in patient safety can be confusing and in addi-
tion clinical specialities have developed their own terminologies.
According to the WHO World Alliance for Patient Safety taxonomy
contained within the International Classication for Patient Safety
[23] the medical safety incidents are dened as:
A patient safety incident is an event or circumstance which
could have resulted, or did result, in unnecessary harm to a
patient.
An adverse event is an incident which results in harm to a
patient.
A near miss is an incident that did not cause harm (also known
as a close call).
An error is a failure to carry out a planned action as intended or
application of an incorrect plan, and may manifest by doing the
wrong thing (an error of commission) or by failing to do the right
thing (an error of omission), at either the planning or execution
phase.
According to the International Nuclear Event Scale (INES) de-
scribed in the IAEA safety glossary an Incident (level 2) is dened
as An event involving signicant failure in safety provisions, but
with sufcient defence in depth remaining to cope with additional
failures and Near miss is dened as A potential signicant event
that could have occurred as the consequence of a sequence of ac-
tual occurrences but did not occur owing to the plant conditions
prevailing at the time [24].
We have used the INES denitions of Incident and Near Miss
described in the IAEA safety glossary wherever possible within this
report because this is the commonest taxonomy in the literature.
However, this needs further discussion within the radiotherapy
community to determine whether a uniform terminology as in
other medical elds could be used in relation to radiotherapy
safety.
We reviewed the worldwide occurrence of radiotherapy treat-
ment incidents and near misses in the last 30 years (from 1976
to 2007) through appraisal of published materials (technical re-
ports, journal articles, guidelines) and unpublished sources of
information such as radiotherapy-related incident data maintained
by the health services. An initial computer-based search of Google
and Google Scholar search engines and PubMed search of the e-
journal collections on radiotherapy, medical physics and nuclear
medicine was performed supplemented by the searches of rele-
vant links for appropriate citations and article bibliographies for
further relevant sources. The key words used were: patient safety,
radiation protection, radiotherapy accident/s, radiotherapy er-
ror/s, radiotherapy incident/s, radiotherapy overexposure, qual-
ity assurance, safety measures and variations of these terms in
combination. In addition, we performed a broader search to iden-
tify relevant literature from developing countries using the above
key words combined with the terms Asia, Africa, developing
countries, Latin America and low and middle income countries.
The bibliography of the individual literature retrieved was iter-
atively searched for additional citations. For articles published in
other languages (e.g. French, Japanese), we reviewed the translated
Decision to
Treat
Simulation,
Imaging & Volume
Determination
Planning
Treatment
Information
Transfer
Assessment
of Patient
Patient Set-up
Treatment
Delivery
Treatment
Review
Prescribing
Treatment
Protocol
Immobilization
&
Positioning
Equipment and
Software
Commissioning
Fig. 1. Radiotherapy process of care [1].
16 Patient safety in radiotherapy
abstracts and veried them with the study ndings from other
sources in English (if available). Our search strategy further in-
cluded selection of the Grey literature (materials that are not for-
mally published) such as working papers, organisational reports
(e.g. IAEA and ICRP reports) and conference proceedings available
from web-based sources.
We also searched for radiotherapy safety-related incidents and
near misses that were available from local, national and interna-
tional databases including the Radiation Oncology Safety Informa-
tion System (ROSIS) database, a voluntary web-based safety
information database for radiotherapy set by a group of medical
physicists and radiation therapists in Europe,
1
data from the UK
peer review report that is in the process of publication
2
and Austra-
lian State-based Department of Radiation Oncology annual incident
reports collection.
3
The incidents were recorded according to the following
categories:
Description
Direct cause/s
Contributing factors
Stage/s (described as in Fig. 1) of the treatment process during
which the incident occurred
Reported impact or outcome
Corrective actions and prevention of future incidents.
We explored and synthesised the data available from all sources
to nd out at what stage most accidents or incidents occurred,
what were the existing deciencies and contributing factors that
led to the errors and how these errors could have been prevented.
A conceptualisation of radiotherapy risk according to the stages of
planning and delivery of treatment was presented in the UK Chief
Medical Ofcers Annual Report in 2006 [25]. This led to clinical
policy recommendations for radiotherapy services in that country.
We developed this further and mapped incidents onto a grid of the
stage of care at which they occurred.
Results
Radiotherapy incidents
A summary of all widely reported major radiotherapy incidents
that led to signicant harm to patients (such as radiation injury
and death) that occurred in the last three decades (19762007)
is presented in Table 1 [13,22,24,26,27,3034,3639]. The coun-
tries of occurrence were middle and high income countries in the
US, Latin America, Europe and Asia. About 3000 (N = 3125) patients
were affected and of them 38 (1.4%) patients were reported to have
died due to radiation overdose toxicity or failures due to under-
dose. Fifty-ve percent of incidents (N = 1702) were in the plan-
ning stage and of the remaining 45%, incidents were due to
errors that occurred during the introduction of new systems and/
or equipment such as megavoltage machines (25%), errors in
treatment delivery (10%), information transfer (9%) or in multiple
stages (1%).
In the years from 1992 to 2007, 4616 near misses that re-
sulted in no recognisable patient harm were identied from the
published literature from European countries, Canada and the
US [14,15,18,28,29,35,40] and unpublished incident reporting
databases from Europe,
1
UK
2
and Australia
3
(Table 1). A major
source (N = 854) of the recent non-injurious events was the
Radiation Oncology Safety Information System (ROSIS) data-
base,
1
a voluntary web-based safety information database for
radiotherapy set-up by a group of radiation therapists and med-
ical physicists) in Europe. Of all such near misses without any
known harm to patients, 9% (N = 420) were related to the plan-
ning stage; 38% (N = 1732) were related to transfer of informa-
tion and 18% (N = 844) to the treatment delivery stage. The
remaining 35% of the incidents occurred in the categories of pre-
scription, simulation, patient positioning or in a combination of
multiple stages.
Fig. 2 describes a summary of injurious incidents including pa-
tient deaths due to radiotherapy toxicity or failure for the last
30 years (N = 3125), the highest number of injurious incidents
(N = 1702, 22% of all) was reported in the planning stage; the
number of deaths (N = 17) was also highest in this stage.
A summary of the potentially highest risk areas in the radio-
therapy process of care and the recommended interventions to im-
prove patient safety, generated through the review of both
published and unpublished radiotherapy incident reports and
through input from the international expert committee of radio-
therapy professionals involved in the development of Radiother-
apy Risk Prole, a WHO Alliance for Patient Safety initiated
radiotherapy safety project [1] is shown in Table 2.
Radiotherapy incidents in developing countries
No detailed reports on radiotherapy-related adverse events
were available from low resource countries in Asia or Africa. The
only published studies are the evaluation of the dosimetry prac-
tices in hospitals in developing countries through the IAEA and
World Health Organisation (WHO) sponsored Thermoluminescent
Dosimetry (TLD) postal dose quality audits carried out on a regular
basis [42,43]. These studies reported that facilities that operate
radiotherapy services without qualied staff or without dosimetry
equipment have poorer results than those facilities that are prop-
erly staffed and equipped. Strengthening of radiotherapy infra-
structure has been recommended for the under-resourced
centres such as those in Latin America and Caribbean to improve
their audit outcomes as comparable to those of developed coun-
tries [42].
An external audit of an Asian oncology practice was able to
identify areas of need in terms of gaps in knowledge and skills
of the staff involved. The study found that about half (52%) of the
patients audited received suboptimal radiation treatment, poten-
tially resulting in compromised cure/palliation or serious morbid-
ity. Inadequate knowledge and skills and high workload of the
radiation oncology staff were described as the reasons for poor
quality of service [44].
Discussion
Although radiotherapy is perceived as risky and complex [25],
the risk of mild to moderate injurious outcome to patients from
radiotherapy errors was about 1500 per million treatment courses
that were much lower than the hospital admission rates for ad-
verse drug reaction in Canada and US (about 65,000 per million
admissions) [45]. Also the reported rate of death from adverse
events in radiotherapy (1%) was lower than the reported rates of
death from the population-based adverse event studies (about 5
14%) [46]. It is apparent that in the earlier 1990s major radiother-
apy incidents occurred mainly due to inexperience in using new
equipment and technology during radiotherapy. These errors
are now much less frequent. In more recent times errors in data
1
ROSIS database: a voluntary safety reporting system for Radiation Oncolgy.
Available from: www.rosis.info [accessed 10 September 2007].
2
Optimising patient safety: reducing errors and incidents in radiotherapy. UK peer
review report (in progress), September 2007.
3
Sydney South West Cancer Services, Radiation oncology treatment related
incident report database 2005.
J. Shaq et al. / Radiotherapy and Oncology 92 (2009) 1521 17
transfer constitute the greatest bulk of radiotherapy-related inci-
dents. These incidents included transcription errors, rounding off
errors, forgotten data or interchange of data and were attributed
to human mistakes or inattention [47]. The United States Nuclear
Regulatory Commission (NRC) that maintains a large database of
radiotherapy misadministration incidents estimated that about
60% or more of misadministrations were due to human errors
[48]. It is now a well recognised challenge in radiotherapy and a
large number of preventative guidelines and safety protocols have
been established by the radiation safety-related authorities at the
local and international level [49,50,10,51,52].
The incidents in radiotherapy which are mainly related to pa-
tient assessment prior to treatment involve history, physical exam-
ination, imaging, biochemical tests, pathology reviews and errors
during radiotherapeutic decision making which involve treatment
intent, tumour type, individual physician practice and type of
equipment used [53]. Comprehensive QA protocols have been
developed that include medical aspects of the radiotherapy treat-
ment such as clinician decisions and patient assessment [7] and
are implemented in several centres in Europe. However, these pro-
tocols have not been widely adopted in the radiotherapy centres
worldwide. This has, amongst other issues, led to a systematic
reporting bias which favours certain types of incidents, particularly
those related to technology rather than clinical judgements. It is
therefore important to view the data analysed in this paper taking
this into consideration.
An evaluation of radiotherapy incident reporting using three
well-known incident data sources, namely, IAEA, ROSIS and NRC
datasets revealed relatively fewer incidents in the Prescription
domain than in the Preparation and Treatment domains [54].
According to the report of a QA meeting in the UK in 2000, much
effort has been directed at QA of system and equipment-related
components of radiotherapy such as planning computers, dosime-
try audit and machine performance. Few initiatives have been ta-
ken to standardize medical processes including target drawing,
the application of appropriate margins and the verication of set-
up involved in radiotherapy [55]. These errors may cause varia-
tions in target delineation leading to changes in the biological
doses that have the potential for a signicant impact in patient
safety.
Studies of radiotherapy practice have shown that the develop-
ment of an explicit and uniform protocol for implementation and
timely assessment of error rates can ensure that incidents are re-
duced to the lowest possible level [14,29]. Systematic minor errors
often suggest problems with infrastructure or information man-
agement that may carry an inherent risk of more serious errors.
Holmberg and McClean [18] claimed that detection and correction
of near misses through practice of a systematic multilayered pre-
treatment check-up system in their centre was preventing occur-
rence of about 14 adverse events per 1000 treatment plans. An-
other recent evaluation at a cancer centre in the United Kingdom
reported a signicant decrease in the number of recorded incidents
Table 1
Chronological summary of radiotherapy incidents and near misses by region and country.
Country Year(s) Causes/contributing factors Incidents with
harm (n)
Near misses
(n)
References
Toxicity Death
USA 19741976 Co-60 unit wrong decay chart 426 [26]
19851987 Therac-25 software programming error 6 3 [27]
1992 Patient sent home with brachytherapy source left inside 1 [26]
19992000 Incorrect data entry, errors in treatment site identication 9 [15]
a
Canada 19891996 Errors in indications for radiotherapy, choice of dose and target
volume critical structures at risk, inhomogeneous dose distribution
234 [28]
19922002 Incorrect treatment plan parameters, data transfer/data
generation errors, errors due to inadequate communication,
incorrect placement of accessories
596 [29]
19972002 Incomplete/incorrect prescription, record and verify (R and V)
system programming errors, calculation errors
555 [14]
20042007 Incorrect output determinations for eld sizes 326
b
[30,31]
Costa Rica 1996 Co-60 unit calibration error 114 6 [32]
Panama 20002001 Wrong data entry into the Computerized Treatment Planning System (TPS) 28 11 [33]
UK 19821991 Inappropriate commissioning of TPS 1045
b
[24]
1988 Co-60 unit calibration error 250 [13]
19881989 Cs-137 brachytherapy source identication error 22 [13]
20002006 Incorrect treatment plan parameters, data transfer errors,
errors in patient positioning, eld size
28 UK peer review
1
20052006 Linac data management system updating error 5 1 [22,34]
Germany 19861987 Co-60 unit wrong dose table 86 [13]
Spain 1990 Linear accelerator (Linac) maintenance error 27 9 [26]
Belgium 19951997 Incomplete/incorrect prescription and calculation errors 1769 [35]
Ireland 19982000 Errors related to TPS utilisation, calculation, and documentation 177 [18]
Poland 2001 Failure of safety recheck on a Linac after power failure 5 [36]
France 20042005 Linac updating error and misinformation errors 25 6 [37,38]
Europe (not specied) 20012007 Incorrect treatment plan parameters, data transfer/data generation errors,
miscommunication errors, errors related to patient identication,
bolus application and block/wedge placement
854 ROSIS database
2
Japan 19902004 Errors related to TPS updating, errors due to inadequate communication 734 1 [39]
Australia 19931995 Errors in prescriptions and planning 235 [40]
2005 Incorrect treatment plan parameters, data transfer/data
generation errors, and errors related to bolus application, shielding
159 (SAC 13)
c
SSW Cancer Services
3
All incidents 3087 38 4616
a
The incidents described were the ones only related to the computerised record and verify system.
b
Radiation underdose of 335% may have lead to high rate of local recurrence.
c
Severity Assessment Code (SAC) is a numerical score applied to an incident based on the type of event, its likelihood of recurrence and its consequence. The scale ranges
from 1 (extreme) to 4 (low) [41].
18 Patient safety in radiotherapy
6
17
13
2
790
1685
276
304
32
3087
38
1
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1000
10000
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Death Overdose/underdose N = 3125
Fig. 2. Radiotherapy incidents with adverse patient outcomes (19762007) by stage of treatment.
Table 2
Potential risk areas ( )
a
in radiotherapy treatment.
Stages Patient factors Equipment or
system factors
Staff factors Suggested preventive
measures
History Clinical
examination
Pathology Communication Guidelines/
protocol
Training No. of
staff
Patient assessment and
decision to treat
Peer review process
Evidence-based
practice
Prescribing treatment
protocol
Peer review process
Standard protocol
Competency
certication
Consultation with
seniors
Immobilisation and
positioning
Competency
certication
QA check and feedback
Incident monitoring
Simulation and Imaging Competency
certication
QA check and feedback
Incident monitoring
Planning QA check and feedback
New staff and equip-
ment orientation
Competency
certication
Incident monitoring
Treatment information
transfer
Clear documentation
Treatment sheet check
Record and verify
system
In vivo dosimetry
Patient set-up Competency
certication
Incident monitoring
Supervisor audit
Treatment delivery Incident monitoring
Imaging/portal lm
In-vivo dosimetry
Treatment review Competency
certication
Incident monitoring
Independent audit
a
Priority measures suggested for the factors with mark in all stages.
J. Shaq et al. / Radiotherapy and Oncology 92 (2009) 1521 19
over the past eight years. Changes in working practices during that
time such as relocation of different procedures, increased use of
specialist staff and regular discussion amongst staff regarding
changes in relation to the requirements of new technology were
identied as factors promoting incident reduction [56].
An important initiative in preventing radiotherapy errors in
decision making and poor or incorrect work practice could be
behavioural modication achieved through frequent audit and reg-
ular peer review of the specialists protocols, processes, procedures
and personnel involved [6,57]. Shakespeare et al. [44] observed
that their audit acted as an informal learning needs assessment
for the radiation oncology staff of the audited centre. They became
more aware of their knowledge and skills gaps and implemented
peer review of all patients simulated, weekly departmental contin-
uing medical education activities, a portal lm review process and
have been performing literature search and peer discussion of dif-
cult cases. They recommended that the establishment of an ade-
quate radiation oncology training system, preferably one based on
available evidence, is an essential element of improved safety prac-
tice, especially in the low income countries [44]. Any investment in
resource development (e.g. time, personnel, and training) would
vary from country to country because of the variability of the
radiotherapy workforce-related costs between high, middle and
low income countries [58]. European experts suggested that taking
initiatives to improve the culture of clinical governance and setting
the standards of practice through medical peer review of target
drawing and dose prescription would be a signicant positive step
in improving the quality of radiotherapy services [55].
In our review, we have added a descriptive summary of inci-
dents categorized according to the stage, examined the causes,
contributing factors, suggestions and recommendations that were
made. The sources that were found described a wide variety of
incidents that occurred all through the radiotherapy process.
Though a large proportion of reported incidents were related to
the system failures due to incorrect use of equipment and set-up
procedures, for a number of them the contributing factors were
incorrect treatment decisions, incorrect treatment delivery and
inadequate verication of treatment due to inexperience and inad-
equate knowledge of the staff involved. These errors were not as
well reported as the system-related errors documented predomi-
nantly by the medical physicists, as observed in our review.
The severity of incidents was not described with a standardised
system and incidents were not collected prospectively. It was not
possible to compare severity between incidents except when the
incident resulted in death. Hence, development of a set of stan-
dards highlighting the patient-centred risk areas in radiotherapy
treatment with suggested improvements tailored to the need of
individual countries and specic departments would be relevant
for all stakeholders. Each radiotherapy service should individually
and repeatedly examine its risk prole and incidents as well as
near misses should be prospectively collected, measured and
categorised.
Conclusion
Radiotherapy-related errors are not uncommon even in the
countries with the highest level of health care resources but
the error rates compare favourably with the rate of other med-
ical errors [46]. It is unrealistic to expect to reduce the error rate
to zero but every effort should be taken to keep the rates low.
Risk model researchers Duffy and Saull say Errors can always
be reduced to the minimum possible consistent with the accu-
mulated experience by effective error management systems
and tracking progress in error reduction down the learning
curve [48]. This can also lead to the identication of incidents
earlier in the process with less serious consequences.
The WHO World Alliance for Patient Safety has taken an ini-
tiative to address the risk areas in the radiotherapy process of
care that is complimentary to the IAEA developed safety mea-
sures and other previously developed standards [1]. Frequent for-
mal and informal staff communication, competency-based
training and regular audits to assess adherence to the protocols
are the top three areas that need to be focused to improve safety
in radiotherapy process.
Role of the funding source
The authors alone are responsible for the views expressed in
this publication and they do not necessarily represent the deci-
sions, policy or views of the World Health Organisation.
Acknowledgements
This paper was funded and supported by the WHO World Alli-
ance for Patient Safety as part of the Radiotherapy Safety Initiative.
Available from: http://www.who.int/patientsafety/activities/tech-
nical/radiotherapy/en/index.html.
Avenue Appia 20, CH-1211 Geneva 27, Switzerland.
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