EPD’s Rath Works To Reduce Errors In Radiotherapy


Contact: Frank Rath
Program Director
University of Wisconsin-Madison
Department of Engineering Professional Development
MADISON, Wis. (7/28/16)–Medical errors are the third leading cause of death in the U.S., and two University of Wisconsin-Madison faculty members are working to reduce the number of errors in radiotherapy (RT).

Bruce Thomadsen, American Association of Physicists in Medicine (AAPM) President-Elect Designate, and Frank Rath, program director for Engineering Professional Development, have been involved in the North American Association of Physicist in Medicine Task Group (TG) 100, which is charged with developing a systematic approach to prevent such errors in RT. The group applied industrial-based quality improvement tools to analyze intensity modulated radiation therapy (IMRT) process. The case study successfully identified many recommendations to improve the quality and safety of the radiotherapy treatment (RT) process.

In addition, the group found a number of “key core components” for quality that are lacking in many RT clinics, including:

  • Standardized procedures
  • Adequate training of staff
  • Clear and effective communication among staff
  • Adequate maintenance of hardware and software
  • Adequate staff, physical and computer resources

The team, which comprised many leading cancer researchers from around the globe, used process mapping, Failure Mode and Effects Analysis (FMEA) and Fault Tree Analysis (FTA) based on their successful use in industry for improving quality management. It also used these tools to analyze a complex RT process, IMRT, as a case study to determine the tools’ potential to improve quality management in RT and demonstrate to the RT community that such techniques can help identify more effective and efficient ways to enhance RT treatment quality and patient safety.

The group’s report* was recently published in the International Journal of Medical Physics Research and Practice.

“To date, most efforts to improve quality in RT have been prescriptive and focused on the equipment,” Thomadsen said. “In reality, many errors that occur in RT are not directly caused by the equipment or software, but are the result of workflow and process problems. The tools TG 100 selected to use to analyze and improve the RT process are specifically tailored for the entire process, including the equipment.”

UW-Madison is planning to provide in-depth training for early adopters of TG 100 and for professionals aspiring to become teachers of the TG 100 methodology.

In addition, Thomadsen; Rath; Rock Mackie, emeritus professor in Medical Physics at UW-Madison and the developer of tomotherapy; and Jatinder Palta, chair of Division of Medical Physics at Virginia Commonwealth University, formed the Center for the Assessment of Radiological Sciences (CARS), a patient safety organization dedicated to improving patient safety and RT treatment quality and preventing errors in radiation oncology. Their first initiative was the creation of an anonymous RT incident reporting system modeled after the successful Federal Aviation Administration incident reporting system.

“Although this program is relatively new, clinics are starting to sign up and contribute,” Rath said. “We’re making some interesting observations and discoveries and developing recommendations to improve RT treatment. In the near future, our plans are to expand the system to include process maps, FMEAs, and FTAs developed by clinics and create a true knowledge-based learning system.”

For more information about this program, or how your clinic can get involved, contact Rath at



* “The Report of Task Group 100 of the AAPM: Application of Risk Analysis Methods to Radiation Therapy Quality Management.” M. Saiful Huq, Benedick A. Fraass, Peter B. Dunscombe, John P. Gibbons Jr., Geoffrey S. Ibbott, Arno J. Mundt, Sasa Mutic, Jatinder R. Palta, Frank Rath, Bruce R. Thomadsen, Jeffrey F. Williamson, and Ellen D. Yorke. (2016).