Radiology can be a complex process using the latest technology, and the results can drive the course of a patient’s care. Getting it right the first time is not always easy, so one health network has found that sending patients through a “dry run” simulation before the actual procedure can improve outcomes and patient safety.

Steven Gresswell, MD, and colleagues in the division of radiation oncology at Allegheny Health Network in Pittsburgh implemented a “verification simulation” across its 11 radiation oncology clinics in 2014.

“It’s an in-depth opportunity for the radiation therapist to own the plan. We bring the patient in a day beforehand and go through everything the radiation therapist does beforehand, all except actually delivering the radiation,” he says. “This allows them to make sure the beam angles and other parameters are correct and that there’s no potential collisions with the linear accelerator.”

The team also verifies the prescription and double-checks all information related to the upcoming procedure.

“If there are any errors, this is an opportunity to fix them in an environment that allows the time to do it,” Gresswell says. “We bring them in for 15-minute or 30-minute appointment slots depending on the complexity of the treatment plan. We saw this as a good opportunity to slow things down, look for any potential issues, and have the time to address them.”

Fewer Incidents With Simulation

The team reported the results in a recent study. They compared success and incident rates with 965 patients in an 18-month period prior to implementation of the verification simulation and 984 patients treated in the same time period with the addition of the dry run.

The dry run typically was scheduled the day before a patient’s first fraction of radiotherapy. Clinicians walked the patient through setup, imaging, and treatment, explaining the process without actual delivery of any radiation.

“The session is designed to allow staff time to verify that the parameters of treatment are accurate and troubleshoot problems in an organized team approach,” Gresswell and his colleagues wrote in their report.

Twenty-eight incidents — errors or potential errors during the dry run or the actual radiography process — were reported in the nonsimulation group, and 18 incidents in the verification simulation cohort. In the simulation group, more incidents also were detected before the day of treatment, and fewer on the day of treatment. They concluded that a verification simulation can be an integral part of any radiation oncology QA program and a risk reduction strategy in the administration of radiotherapy.

Less Anxiety for Patients

Though it was not the aim of the project, they found that 83% of patients reported decreased anxiety because of the dry run.

“Error identification in radiation therapy is critical to maintaining a safe and efficient therapeutic environment,” the authors wrote. “A verification simulation for patient information provides a dedicated time prior to treatment to duplicate steps of patient setup, imaging, and treatment processes as a final quality assurance step.”

(An abstract of the report is available online at:

Gresswell notes that the findings were not exactly what he expected. There were fewer incidents reported in the simulation group when he expected to see more just because there were two opportunities to spot errors — the dry run and the actual treatment.

“That might be because the errors were caught before they could lead to more errors down the road. They were caught in the simulation and addressed instead of going unseen and leading to other incidents on the day of treatment,” he says. “When we have the dry run in place, that also gives the radiation therapists more time to do their jobs, and we found more of the incidents were detected by the radiation therapists. That was good to see.”