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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 following links:



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 and confidentiality.  

The charges of the Committee are as follows:

  1. 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.
  2. Develop/maintain a format and mechanism for state programs to provide the committee with details of reportable events.
  3. Review submitted reports for completeness and accuracy, and develop notices to the state programs when necessary.
  4. Oversee the development and maintenance of a CRCPD database of reportable events.
  5. Prepare an annual summary report for the CRCPD Board and the Newsbrief.  
  6. 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.