CRCPD to Pilot Tracking
System for Machine-Based Radiation Medical Events
The Conference of Radiation Control Program
Directors (CRCPD), a national non-governmental professional
organization dedicated to radiation protection, has identified
medical radiation overexposures and misadministration as an
important issue. Recent
articles in the press have brought medical events involving
radiation machines to the public's attention, such as those in the
However, for the past several years, CRCPD
members had become concerned that such events should be reported,
investigated, and tracked.
The CRCPD's Suggested State Regulations for Control of
Radiation Part X on Medical Therapy contains a provision that
requires the reporting of therapy misadministrations.
In addition, the feasibility of a national database of such
events was discussed at the CRCPD Business Meeting during the May
2009 National Conference on Radiation Control.
Although the overall benefit and safety record
for radiation therapy and other radiation procedures is quite high,
errors in administration should be tracked for causes and trends.
The CRCPD is in the process of staffing a committee to
develop a pilot project to collect data on radiation machine-based
events from state radiation control programs that will take into
account states differences in laws/regulations regarding reporting
The charges of the Committee are as follows:
Develop a definition of reportable events to include radiation
therapy using linear accelerators and e-brachytherapy
technology, as well as high dose diagnostic procedures such as
computed tomography (CT) and fluoroscopy.
Develop/maintain a format and mechanism for state programs to
provide the committee with details of reportable events.
Review submitted reports for completeness and accuracy, and
develop notices to the state programs when necessary.
Oversee the development and maintenance of a CRCPD database of
Prepare an annual summary report for the CRCPD Board and the
Provide a verbal report at the Annual Meeting.
The data reporting will be done on a voluntary basis and will be
used to inform and educate interested parties on trends, root
causes, and methods for improvement.