Improving the safety of radiotherapy treatment delivery

  • Lucy Gilbert

Student thesis: Doctoral ThesisDoctor of Philosophy


Errors during radiotherapy treatment can cause severe, and potentially fatal, patient harm. The final check immediately prior to treatment delivery, whereby two radiographers ensure that the dose about to be delivered corresponds with the prescription ,is the last defence against error. The aim of this research was to increase understanding of this final treatment check and factors affecting error detection, in order to improve the safety of radiotherapy treatment delivery.

The research adopted a mixed methods approach, combining qualitative and experimental studies to investigate the interaction of factors affecting accuracy during the final treatment checks. The qualitative interviews and task analysis pointed to difficulties maintaining attention and variation in how these checks are conducted. The interface used to conduct the final treatment check was also recognised to have usability issues.

The laboratory-based experimental studies results indicated that a structured form of double checking, called challenge-response, is most effective at error detection, when compared to single or unstructured double checking. Furthermore, it was found that alternating the roles of challenger and responder, and the order parameters are checked in, significantly increases accuracy during repeated treatment checks.

The original contribution of this research was a detailed investigation of a previously understudied aspect of radiotherapy treatment. The results informed the design of an original, evidence and theoretical based two-person checking protocol for use during the final treatment check. Qualitative evaluation indicates that it would be well received as a standardised method of treatment checking. Furthermore, an alternative interface design has been proposed, specifically for use during the final treatment check. This was comparatively tested against the most frequently used software package within the UK and found to have a significant positive impact upon user’s accuracy. An additional output is a series of practice based recommendations to improve accuracy during repeated treatment checking.

This research has concluded that implementation of the practice recommendations, checking protocol and interface design should help maintain radiographers’ attention during repeated final treatment checks, thereby preventing errors passing undetected. Future research into the radiotherapy interface design and implementation of the standardised final treatment check protocol have been identified.

Date of Award2015
Original languageEnglish
Awarding Institution
  • Coventry University

Cite this