Key Publications in the Area

Reijnders-Thijssen P, Geerts D, van Elmpt W, Pawlicki T, Wallis A, Coffey M. Prevalence of software alerts in radiotherapy. Technical Innovations & Patient Support in Radiation Oncology. 2020;14:32-35.

Anderson N, Thompson K, Andrews J, Chesson B, Cray A, Phillips D, Ryan M, Soteriou S, Trainor G, Touma N. Planning for a pandemic: Mitigating risk to radiation therapy service delivery in the COVID‐19 era. Journal of Medical Radiation Sciences. Sep 2020;67(3):243-248.

Franco P, Tesio V, Bertholet J, Gasnier A, Gonzalez Del Portillo E, Spalek M, Bibault JE, Borst G, Van Elmpt W, Thorwarth D, Mullaney L, Røe Redalen K, Dubois L, Chargari C, Perryck S, Heukelom J, Petit S, Lybeer M, Castelli L. Professional quality of life and burnout amongst radiation oncologists: The impact of alexithymia and empathy. Radiother Oncol. 2020 Jun;147:162-168.

Smith S, Wallis A, King O, Moretti D, Vial P, Shafiq J, Barton M, Delaney GP. Quality Management in Radiation Therapy: A 15 year review of incident reporting in two integrated cancer centres. Technical Innovations & Patient Support in Radiation Oncology. 2020; 14:15-20.

Liszewski B. A prioritization framework for the analysis of near misses in radiation oncology. Tech Innov Patient Support Radiat Oncol. 2020 Jun 12;14:36-42.

Ralston A, Yuen J. Use of the AAPM safety profile assessment tool to evaluate the change in safety culture after implementing the RABBIT prospective risk management system. Advances in radiation oncology. 2019 Jan ;4(1):150-155.

Evans SB, Cain D, Kapur A, Brown D, Pawlicki T. Why Smart Oncology Clinicians do Dumb Things: A Review of Cognitive Bias in Radiation Oncology. Pract Radiat Oncol. 2019 JulAug;9(4):e347-e355.

Leonard S, O’Donovan A. Measuring safety culture: Application of the Hospital Survey on Patient Safety Culture to radiation therapy departments worldwide. Pract Radiat Oncol. 2018 Jan-Feb;8(1):e17-e26.

Liszewski B, Angers C, Kildea J. Mitigating the Barriers to a Culture of Quality and Safety in Radiation Oncology. Clin Oncol. 2017 Oct;29(10):676-679.

Delaney G P, Davies J M. Can the Aviation Industry be Useful in Teaching Oncology about Safety? Clin Oncol. 2017;29:669-675.

Pawlicki T, Coffey M, Milosevic M. Incident Learning Systems for radiation oncology: Development and Value at the local, national and international level. Clin Oncol. 2017;29(9):562-567.

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Jr., Ibbott GS, Mundt AJ, et al. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Med Phys. 2016;43(7):4209-62.

Teixeira FC, de Almeida CE, Saiful Huq M. Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil. Med Phys. 2016;43(1):171-78.

Delaney G P. Safety in Radiotherapy mini-series. Clin Oncol. 2017 ;29:553-554.

Delaney G P, Papadatos G. Medical Error e the Perspective of the Clinician and the Director of a Department Involved in an Error. Clin Oncol. 2017;29:555-556.

Knöös T. Lessons Learnt from Past Incidents and Accidents in Radiation Oncology. Clin Oncology. 2017;29: 557-561.

Naessens E D. Medical Error: a Patient’s Perspective. Clin Oncol. 2017;29 : 667-668.

Malicki J, Bly R, Bulot M, Godet J-L, Jahnen A, Krengli M, Maingon P, Prieto Martin C, Przybylska K, Skrobała A, Valero M, Jarvinen H. Patient safety in external beam radiotherapy, results of the ACCIRAD project: Current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe. Radiotherapy and Oncology. 2017; 123(1): 29-36.

Woodhouse K D, Volz E, Bellerive M, Bergendahl H W, Gabriel P E, Maity A, Hahn S M, Vapiwala N. The implementation and assessment of a quality and safety culture education program in a large radiation oncology department. Pract Radiat Oncol. 2016; 6(4): e127-e134.

Milosevic M, Angers C, Liszewski B, Parliament M, Ross S, Brundage M. The Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT) Taxonomy. Pract Radiat Oncol. 2016; 6(2):334-341.

Teixeira F C, de Almeida C E, Saiful Huq M. Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil. Med Phys. 2016;43(1):171-78.

Walker G V, Johnson J, Edwards T, Gatilao R A, Hayden S E, Riley B A, Sittig D F, Gillin M, Ibbott G, Buchholz T A, Das P. Factors associated with radiation therapy incidents in a large academic institution. Practical Radiation Oncology. 2015; 5(1): 21-27.

Knöös T. QA procedures needed for advanced RT techniques and its impact on treatment outcome.  Journal of Physics: Conference Series 573. 2015; 012001.

Dunscombe P, Brown D, Donaldson H, Greener A, O’Neill M, Sutlief S, et al. Safety Profile Assessment: An online tool to gauge safety-critical performance in radiation oncology. Pract Radiat Oncol. 2015;5(2):127-34.

Mayadev J, Dieterich S, Harse R, Lentz S, Mathai M, Boddu S, et al. A failure modes and effects analysis study for gynecologic high-dose- rate brachytherapy. Brachytherapy. 2015;14(6):866-875.

Simons PAM Houben R, Vlayen A, Hellings J, Pijls-Johannesma M, Marneffe W, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute. Eur J Oncol Nurs. 2015;19(1):29-37.

Yang F, Cao N, Young L, Howard J, Logan W, Arbuckle T, et al. Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy. Med Phys. 2015;42(6):2777-85.

Ford EC, Smith K, Terezakis S, Croog V, Gollamudi S, Gage I, et al. A streamlined failure mode and effects analysis. Med Phys. 2014;41(6):061709.

Simons PAM, Houben R, Benders J, Pijls-Johannesma M, Vandijck D, Marneffe W, et al. Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized? Eur J Oncol Nurs. 2014;18(5):459-65.

Smith KS, Harris KM, Potters L, Sharma R, Mutic S, Gay HA, et al. Physician attitudes and practices related to voluntary error and near-miss reporting. J Oncol Pract. 2014;10(5):e350-e57.

Williams MV. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol.2014; 80(953):297-301.

Perks JR, Stanic S, Stern RL, Henk B, Nelson MS, Harse RD, et al. Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. International Int J Radiat Oncol Biol Phys. 2012;83(4):1324-29.

Ritter T, Balter JM, Lee C, Roberts D, Roberson PL. Audit tool for external beam radiation therapy departments. Practical Radiat Oncol. 2012;2(4):e39-e44.

Marks L B, Jackson M, Xie L, Chang S X, Deschesne Burkhardt K, Mazur L, Jones E L, Saponaro P, Dana Lachapelle D, Baynes D C, Adams R D. The challenge of maximizing safety in radiation oncology. Pract Radiat Oncol. Jan-Mar 2011;1(1):2-14.

Bissonnette J-P, Medlam G. Trend analysis of radiation therapy incidents over seven years. Radiother & Oncol. 2010;96(1):139-44.

Ford EC, Terezakis S. How Safe Is Safe? Risk in Radiotherapy. Int J Radiat Oncol Biol Phys. 2010;78(2):321-322.

Simons PAM, Houben RMA, Backes HH, Pijls RFG, Groothuis S. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Int J Qual Health Care. 2010;22(3):187-93.

Rasmussen B and Chu K. TH-C-203-04: Implementation of a “Time Out” Procedure in Radiation Oncology: A Multi-Institution Study over Nine Years Results in a Three-Fold Reduction in Misadministrations. Med. Phys. June 2010; 37(6): 3450-3451.

Boadu M, Rehani MM. Unintended exposure in radiotherapy: Identification of prominent causes. Radiother & Oncol. 2009;93(3):609-17.

Ford EC, Gaudette R, Myers L, Vanderver B, Engineer L, Zellars R, et al. Evaluation of Safety in a Radiation Oncology Setting Using Failure Mode and Effects Analysis. Int J Radiat Oncol Biol Phys. 2009;74(3):852-58.

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. An international review of patient safety measures in radiotherapy practice. Radiother & Oncol. 2009;92(1):15-21.

Habraken M M P, Van der Schaaf T W, Leistikow I P and Reijnders-Thijssen P M J. Prospective risk analysis of health care processes: A systematic evaluation of the use of HFMEA™ in Dutch health care. Ergonomics. 2009; 52(7): 809-819.

Rivera AJ, Karsh B-T. Human Factors and Systems Engineering Approach to Patient Safety for Radiotherapy. Int J Radiat Oncol Biol Phys. 2008;71(1, Supplement):S174-S77.

Williamson JF, Dunscombe PB, Sharpe MB, Thomadsen BR, Purdy JA, Deye JA. Quality Assurance Needs for Modern Image-Based Radiotherapy: Recommendations From 2007 Interorganizational Symposium on “Quality Assurance of Radiation Therapy: Challenges of Advanced Technology”. Int J Radiat Oncol Biol Phys.2008;71(1, Supplement):S2-S12.

Ash D. Lessons from Epinal. Clinical Oncol. 2007;19(8):614-5.

Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211-16.

Reason J. Understanding adverse events: human factors. BMJ Qual Saf. 1995;4(2):80-9.

Ash D, Bates T. Report on the clinical effects of inadvertent radiation underdosage in 1045 patients. Clinical Oncol.1994;6(4):214-26.

ROSEIS Publications

Cunningham J. Radiation Oncology Safety Information System (ROSIS): A Reporting and Learning System for Radiation Oncology. PhD Thesis. Dublin: Trinity College Dublin; 2011. Available from: [Accessed 14 May 2021]

Cunningham J, Coffey M, Knöös T, Holmberg O: Radiation Oncology Safety Information System (ROSIS) – Profiles of participants and the first 1074 incident reports. Radiotherapy and Oncology. 2010; 97(3):601-7.

Cunningham, J, Coffey, M, Holmberg, O, Knoos, T. A global standard for incident reporting in radiation therapy using the rosis classification system. (ROSIS = Radiation Oncology Safety Information System). Radiotherapy and Oncology. 2007;84 (1, Supplement):S59.

Holmberg, O, Cunningham, J, Coffey, M, Knöös, T. ROSIS network. Radiotherapy & Oncology. 2006;81(1, Supplement):S125.

Cunningham, J, Coffey, M, Holmberg, O, Knöös, T. ROSIS (Radiation Oncology Safety Information System) Recognising risk, enhancing safety. Radiotherapy & Oncology.2004;73(1, Supplement):S220.

do Carmo Lopes, M. To become an active department in the ROSIS project: process and evaluation. Radiotherapy & Oncology.2004;73(1, Supplement):S220.

Cunningham, J, Coffey, M, Holmberg, O, Knöös, T. The ROSIS project. Radiotherapy & Oncology.2003;68(1, Supplement):S78.




ESTRO ROSQ Committee Webinar Series

The series has been designed to provide knowledge and understanding of the issues underpinning safe practice from both the patient and staff perspective.