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WE-H-204-01: William D. Coolidge, Inventor of the Modern X-Ray Tube

“William D. Coolidge, Inventor of the Modern X-ray Tube” David J. Allard, M.S., CHP - Director, PA DEP Bureau of Radiation Protection William David Coolidge 1873–1975 was a research scientist and inventor of the modern X-ray tube. Besides Roentgen, with his 1895 discovery and subsequent studies of X-rays, perhaps no other individual contributed more to the advancement of X-ray technology than did Coolidge. He was born in Hudson, MA and received his Bachelor of Science degree from MIT in 1896. That same year he went to Europe to study under renowned physicists of the time. Coolidge received his Ph.D. summa cum laude from the University of Leipzig in 1899 and soon after joined the staff of MIT. While studying at Leipzig, he met Roentgen. In 1905 he was asked to join the newly established General Electric Research Laboratory in Schenectady, NY. He promptly began fundamental work on the production of ductile tungsten filaments as a replacement for fragile carbon filaments used in incandescent light bulbs. This improved light bulb was brought to market by GE in 1911. It was subsequent application of his tungsten work that led Coolidge to his studies in X ray production. Circa 1910, the state-of-the-art X-ray tube was a “gas tube” or “cold cathode” type tube. These crude X-ray tubes relied on residual gas molecules as a source of electrons for bombardment of low to medium atomic number metal targets. In 1912 Coolidge described the use of tungsten as an improved anode target material for X-ray tubes. Shortly after in 1913 he published a paper in Physical Review describing “A Powerful Roentgen Ray Tube With a Pure Electron Discharge.” This tube used a tungsten filament as a thermionic source of electrons under high vacuum to bombard a tungsten anode target. Great improvements in X-ray tube stability, output and performance were obtained with the “hot cathode” or “Coolidge tube.” With some variation in filament and target geometry, this 100 year old invention is the same basic X-ray tube used today in medicine, research and industry. In 1932 Coolidge became Director of the GE Laboratory, then in 1940 Vice-President and Director of Research. In 1941 he was a member of a small committee, appointed by President Franklin D. Roosevelt, to evaluate the military importance of research on uranium. This committee’s report led to the establishment of the Manhattan Engineering District for nuclear weapons development during WWII. Coolidge lived to be over 100 years old, he had 83 patents to his credit, numerous awards and honorary degrees, and in 1975 was elected to the National Inventor’s Hall of Fame. At the time he was the only inventor to receive this honor in his lifetime. Dr. Coolidge was also the first recipient of the AAPM’s highest science award - named in his honor. From notes of a day-long interview with Coolidge’s son Lawrence in the mid-1990s, previous biographies, publications, books, GE literature, historic photographs, e.g., a wonderful 1874 photo stereoview card with 1 year old baby “Willie Coolidge”, and other artifacts in the author’s collection, this presentation will review Dr. Coolidge’s amazing life, work, accomplishments and awards. “History and Archives Resources at AIP for AAPM and its Members” Gregory A. Good, Ph.D. - Director, AIP Center for History of Physics Melanie J. Mueller, MLIS - Acting Director, AIP Niels Bohr Library & Archives The American Institute of Physics established the Center for History of Physics and the Niels Bohr Library & Archives in the 1960s. Our shared mission is: To preserve and make known the history of the physical sciences. This talk will explore the many ways that AIP’s two history programs support the historical and archival activities of AAPM. Topics will include our ongoing oral history program, web outreach through exhibits and teaching guides, and archiving for AAPM and other Member Societies. We will focus in particular on materials in our collections related to the history of medical physics and to the history of AAPM. We will unveil and demonstrate a new “Archives Portal” that we are designing specifically to be useful to AAPM and its members. Learning Objectives: Study the background of the medical physicist - William David Coolidge Examine the time-line for his success Review the publications conceptualizing his works and progressions Realize what he invented Evaluate the importance of the invention Relate the success to national prominence Uncover how he influenced medical physicists today Find out how he was celebrated by the AAPM View the AIP established Center for History of Physics Consider the significant efforts and vision to preserve the history of medical physics Learn about the Niels Bohr Library & Archives Look back in time at medical physics in the 1960s Unveil and demonstrate a new “Archives Portal” that will be useful to AAPM.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

WE-H-204-02: Part 1: History and Archives Resources at AIP for AAPM and Its Members

“William D. Coolidge, Inventor of the Modern X-ray Tube” David J. Allard, M.S., CHP - Director, PA DEP Bureau of Radiation Protection William David Coolidge 1873–1975 was a research scientist and inventor of the modern X-ray tube. Besides Roentgen, with his 1895 discovery and subsequent studies of X-rays, perhaps no other individual contributed more to the advancement of X-ray technology than did Coolidge. He was born in Hudson, MA and received his Bachelor of Science degree from MIT in 1896. That same year he went to Europe to study under renowned physicists of the time. Coolidge received his Ph.D. summa cum laude from the University of Leipzig in 1899 and soon after joined the staff of MIT. While studying at Leipzig, he met Roentgen. In 1905 he was asked to join the newly established General Electric Research Laboratory in Schenectady, NY. He promptly began fundamental work on the production of ductile tungsten filaments as a replacement for fragile carbon filaments used in incandescent light bulbs. This improved light bulb was brought to market by GE in 1911. It was subsequent application of his tungsten work that led Coolidge to his studies in X ray production. Circa 1910, the state-of-the-art X-ray tube was a “gas tube” or “cold cathode” type tube. These crude X-ray tubes relied on residual gas molecules as a source of electrons for bombardment of low to medium atomic number metal targets. In 1912 Coolidge described the use of tungsten as an improved anode target material for X-ray tubes. Shortly after in 1913 he published a paper in Physical Review describing “A Powerful Roentgen Ray Tube With a Pure Electron Discharge.” This tube used a tungsten filament as a thermionic source of electrons under high vacuum to bombard a tungsten anode target. Great improvements in X-ray tube stability, output and performance were obtained with the “hot cathode” or “Coolidge tube.” With some variation in filament and target geometry, this 100 year old invention is the same basic X-ray tube used today in medicine, research and industry. In 1932 Coolidge became Director of the GE Laboratory, then in 1940 Vice-President and Director of Research. In 1941 he was a member of a small committee, appointed by President Franklin D. Roosevelt, to evaluate the military importance of research on uranium. This committee’s report led to the establishment of the Manhattan Engineering District for nuclear weapons development during WWII. Coolidge lived to be over 100 years old, he had 83 patents to his credit, numerous awards and honorary degrees, and in 1975 was elected to the National Inventor’s Hall of Fame. At the time he was the only inventor to receive this honor in his lifetime. Dr. Coolidge was also the first recipient of the AAPM’s highest science award - named in his honor. From notes of a day-long interview with Coolidge’s son Lawrence in the mid-1990s, previous biographies, publications, books, GE literature, historic photographs, e.g., a wonderful 1874 photo stereoview card with 1 year old baby “Willie Coolidge”, and other artifacts in the author’s collection, this presentation will review Dr. Coolidge’s amazing life, work, accomplishments and awards. “History and Archives Resources at AIP for AAPM and its Members” Gregory A. Good, Ph.D. - Director, AIP Center for History of Physics Melanie J. Mueller, MLIS - Acting Director, AIP Niels Bohr Library & Archives The American Institute of Physics established the Center for History of Physics and the Niels Bohr Library & Archives in the 1960s. Our shared mission is: To preserve and make known the history of the physical sciences. This talk will explore the many ways that AIP’s two history programs support the historical and archival activities of AAPM. Topics will include our ongoing oral history program, web outreach through exhibits and teaching guides, and archiving for AAPM and other Member Societies. We will focus in particular on materials in our collections related to the history of medical physics and to the history of AAPM. We will unveil and demonstrate a new “Archives Portal” that we are designing specifically to be useful to AAPM and its members. Learning Objectives: Study the background of the medical physicist - William David Coolidge Examine the time-line for his success Review the publications conceptualizing his works and progressions Realize what he invented Evaluate the importance of the invention Relate the success to national prominence Uncover how he influenced medical physicists today Find out how he was celebrated by the AAPM View the AIP established Center for History of Physics Consider the significant efforts and vision to preserve the history of medical physics Learn about the Niels Bohr Library & Archives Look back in time at medical physics in the 1960s Unveil and demonstrate a new “Archives Portal” that will be useful to AAPM.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

WE-H-204-03: Part 2: History and Archives Resources at AIP for AAPM and Its Members

“William D. Coolidge, Inventor of the Modern X-ray Tube” David J. Allard, M.S., CHP - Director, PA DEP Bureau of Radiation Protection William David Coolidge 1873–1975 was a research scientist and inventor of the modern X-ray tube. Besides Roentgen, with his 1895 discovery and subsequent studies of X-rays, perhaps no other individual contributed more to the advancement of X-ray technology than did Coolidge. He was born in Hudson, MA and received his Bachelor of Science degree from MIT in 1896. That same year he went to Europe to study under renowned physicists of the time. Coolidge received his Ph.D. summa cum laude from the University of Leipzig in 1899 and soon after joined the staff of MIT. While studying at Leipzig, he met Roentgen. In 1905 he was asked to join the newly established General Electric Research Laboratory in Schenectady, NY. He promptly began fundamental work on the production of ductile tungsten filaments as a replacement for fragile carbon filaments used in incandescent light bulbs. This improved light bulb was brought to market by GE in 1911. It was subsequent application of his tungsten work that led Coolidge to his studies in X ray production. Circa 1910, the state-of-the-art X-ray tube was a “gas tube” or “cold cathode” type tube. These crude X-ray tubes relied on residual gas molecules as a source of electrons for bombardment of low to medium atomic number metal targets. In 1912 Coolidge described the use of tungsten as an improved anode target material for X-ray tubes. Shortly after in 1913 he published a paper in Physical Review describing “A Powerful Roentgen Ray Tube With a Pure Electron Discharge.” This tube used a tungsten filament as a thermionic source of electrons under high vacuum to bombard a tungsten anode target. Great improvements in X-ray tube stability, output and performance were obtained with the “hot cathode” or “Coolidge tube.” With some variation in filament and target geometry, this 100 year old invention is the same basic X-ray tube used today in medicine, research and industry. In 1932 Coolidge became Director of the GE Laboratory, then in 1940 Vice-President and Director of Research. In 1941 he was a member of a small committee, appointed by President Franklin D. Roosevelt, to evaluate the military importance of research on uranium. This committee’s report led to the establishment of the Manhattan Engineering District for nuclear weapons development during WWII. Coolidge lived to be over 100 years old, he had 83 patents to his credit, numerous awards and honorary degrees, and in 1975 was elected to the National Inventor’s Hall of Fame. At the time he was the only inventor to receive this honor in his lifetime. Dr. Coolidge was also the first recipient of the AAPM’s highest science award - named in his honor. From notes of a day-long interview with Coolidge’s son Lawrence in the mid-1990s, previous biographies, publications, books, GE literature, historic photographs, e.g., a wonderful 1874 photo stereoview card with 1 year old baby “Willie Coolidge”, and other artifacts in the author’s collection, this presentation will review Dr. Coolidge’s amazing life, work, accomplishments and awards. “History and Archives Resources at AIP for AAPM and its Members” Gregory A. Good, Ph.D. - Director, AIP Center for History of Physics Melanie J. Mueller, MLIS - Acting Director, AIP Niels Bohr Library & Archives The American Institute of Physics established the Center for History of Physics and the Niels Bohr Library & Archives in the 1960s. Our shared mission is: To preserve and make known the history of the physical sciences. This talk will explore the many ways that AIP’s two history programs support the historical and archival activities of AAPM. Topics will include our ongoing oral history program, web outreach through exhibits and teaching guides, and archiving for AAPM and other Member Societies. We will focus in particular on materials in our collections related to the history of medical physics and to the history of AAPM. We will unveil and demonstrate a new “Archives Portal” that we are designing specifically to be useful to AAPM and its members. Learning Objectives: Study the background of the medical physicist - William David Coolidge Examine the time-line for his success Review the publications conceptualizing his works and progressions Realize what he invented Evaluate the importance of the invention Relate the success to national prominence Uncover how he influenced medical physicists today Find out how he was celebrated by the AAPM View the AIP established Center for History of Physics Consider the significant efforts and vision to preserve the history of medical physics Learn about the Niels Bohr Library & Archives Look back in time at medical physics in the 1960s Unveil and demonstrate a new “Archives Portal” that will be useful to AAPM.

46 INSTRUMENTATION RELATED TO NUCLEAR SCIENCE AND ↗

Production of Medically Important Radionuclides 52 Mn and 90 Nb

Over the final reporting period of this project, we at MGH finalized our effort on Project 2: Production and Characterization of 90 Nb which, as per our previous report led us to an interesting application of mass spectrometry in radiometal chemistry. Overall, our research has developed parameters and procedures for delivering high 90 Nb for preclinical and translational applications by initializing the cyclotron targetry and separation chemistry for delivering 90 Nb in a chemical form suitable for subsequent development of 90 Nb-based PET radiotracers, and most recently we have published on the mass spectrometry applications described in the present report. We have been working with MSKCC (PI Jason Lewis) on the 90 Nb methodology and have had input from UAB (PI Suzy Lapi). An in-person meeting was held during the upcoming funding period with 2 PIs who are co-organizing the Radiochemistry Symposium (Lapi and Vasdev) and Program Director Dr. Ethan Balkin, during the ACS National Meeting in March 2018, and 2 PIs (Lewis and Vasdev) co presented in at the World Federation of Nuclear Medicine and Biology at a symposium sponsored by the Australian Nuclear Sciences and Technology Organisation, where they are both collaborating, in Melbourne, Australia in April 2018. Future projects and collaborations are under discussion with the Lapi lab to focus on new applications of 76 Br chemistry, and a new collaboration has already resulted with the Lewis lab on 18 F radiochemistry that employ iodonium ylide based precursors developed in the Vasdev lab, for clinical production of [ 18 F]MFBG. It is noteworthy that the PI has now relocated to the University of Toronto and has 2 cyclotrons (IBA Cyclone and Scanditronix MC-17) that will also be used to explore new 11 C-radiochemistry including [ 11 C]CO.

07 ISOTOPE AND RADIATION SOURCES↗

Energy Equity and Environmental Justice Summit Report 2022

Pacific Northwest National Laboratory (PNNL) hosted a limited-engagement Energy Equity and Environmental Justice (EEEJ) Summit on September 28, 2022, with the Department of Energy (DOE) Office of Economic Impact and Diversity (DOE-ED) and DOE national laboratories: Argonne National Laboratory, Idaho National Laboratory, Lawrence Livermore National Laboratory, National Renewable Energy Laboratory, Oak Ridge National Laboratory, Sandia National Laboratories, and Savannah River National Laboratory. The goal of the Summit was for labs to highlight their capabilities in the EEEJ space and connect them to DOE-ED’s mission and goals as well as share lessons learned and best practices in our various programmatic spaces. The event commenced with an opening address from Director Shalanda Baker (DOE-ED), which included a call to action for the national labs. Three presentation panels followed, giving insights to the programs stewarded by national laboratories that are currently taking steps to enhance the way science is implemented through equity and justice lenses. A roundtable discussion concluded the Summit and highlighted lessons learned, gaps, challenges, opportunities, and future needs that will improve the impact and partnership of EEEJ work at DOE, national laboratories, at other agencies and institutions, and in other programmatic areas. Interest among participants to stay connected and coordinated and to partner on EEEJ work across labs was emphasized, including a suggestion to establish an intra-laboratory community of practice.

54 ENVIRONMENTAL SCIENCES↗

Managing Risk on the Final Frontier

The National Aeronautics and Space Administration (NASA). Exploration Systems Mission Directorate (ESMD) has combined the Continuous Risk Management (CRM) discipline with innovative knowledge management (KM) practices to more effectively enable the accomplishment of work. CRM enables proactive problem identification and problem solving in the complex world of rocket science. while KM is used to improve this process.

Lengyel, David M.↗

Fundamental Aeronautics Program

The Overarching Mission of NASA's Aeronautics Research Mission Directorate (ARMD) is: To advance U.S. technological leadership in aeronautics in partnership with industry, academia, and other government agencies that conduct aeronautics-related research. ARMD supports the Agency's goal of developing a balanced overall program of science, exploration, and aeronautics, and ARMD's research plans also directly support the National Aeronautics R&D Policy and accompanying Executive Order 131419.

Misra, Ajay↗

The Wonders of Physics -- Public Outreach (Final Technical Report)

The mission of The Wonders of Physics (TWoP) outreach program is to generate interest in physics among people of all ages and backgrounds. The objective is to generate interest in physics, increase appreciation for the significance of physics in our lives, and encourage children to consider careers in science and plasma physics. The primary means for achieving that objective is to make entertaining presentations to audiences that would not normally be motivated to attend a lecture on physics or plasmas, while at the same time introducing some of the fundamental concepts and applications. During this reporting period, the students Michael Hall, Megan Tabbutt and Connor Sullivan, Director of Communications Sarah Perdue, Director of Undergraduate Program Jim Reardon, and Senior Information Processing Consultant Paul Wilhite worked to make outreach programs a success and prepare for the future of The Wonders of Physics, which will continue. Because of the curtailment of public events due to Covid-19, there will not be an in person Annual Show or Physics Fair in 2021, but a video competition has already been announced and planning continues for The Wonders of Physics in 2022 and beyond. The annual shows and Physics Fair are scheduled for February 12-13 and February 19-20, 2022. These continue to be our premier outreach events, engaging diverse audiences in real hands-on science. Further shows and exploration stations are planned.

70 PLASMA PHYSICS AND FUSION TECHNOLOGY↗

Lessons Learned Study Final Report for the Exploration Systems Mission Directorate

This report is the final product of a 90-day study performed for the Exploration Systems Mission Directorate. The study was to assemble lessons NASA has learned from previous programs that could help the Exploration Systems Mission Directorate pursue the Exploration vision. It focuses on those lessons that should have the greatest significance to the Directorate during the formulation of program and mission plans. The study team reviewed a large number of lessons learned reports and data bases, including the Columbia Accident Investigation Board and Rogers Commission reports on the Shuttle accidents, accident reports from robotic space flight systems, and a number of management reviews by the Defense Sciences Board, Government Accountability Office, and others. The consistency of the lessons, findings, and recommendations validate the adequacy of the data set. In addition to reviewing existing databases, a series of workshops was held at each of the NASA centers and headquarters that included senior managers from the current workforce as well as retirees. The full text of the workshop reports is included in Appendix A. A lessons learned website was opened up to permit current and retired NASA personnel and on-site contractors to input additional lessons as they arise. These new lessons, when of appropriate quality and relevance, will be brought to the attention of managers. The report consists of four parts: Part 1 provides a small set of lessons, called the Executive Lessons Learned, that represent critical lessons that the Exploration Systems Mission Directorate should act on immediately. This set of Executive Lessons and their supporting rationale have been reviewed at length and fully endorsed by a team of distinguished NASA alumni; Part 2 contains a larger set of lessons, called the Selected Lessons Learned, which have been chosen from the lessons database and center workshop reports on the basis of their specific significance and relevance to the near-term work of the Exploration Directorate. These lessons frequently support the Executive lessons but are more general in nature; Part 3 consists of the reports of the center workshops that were conducted as part of this activity. These reports are included in their entirety (approximately 200 pages) in Appendix G and have significance for specific managers; Part 4 consists of the remainder of the lessons that have been selected by this effort and assembled into a database for the use of the Explorations Directorate. The database is archived and hosted in the Lessons Learned Knowledge Network, which provides a flexible search capability using a wide variety of search terms. Finally, a spreadsheet lists databases searched and a bibliography identifies reports that have been reviewed as sources of lessons for this task. NASA has been presented with many learning opportunities. We have conducted numerous programs, some extremely successful and others total failures. Most have been documented with a formal lessons learned activity, but we have not always incorporated these learning opportunities into our normal modes of business. For example, the Robbins Report of 2001 clearly indicates that many project failures of the past two decades were the result of violating well documented best practices, often in direct violation of management instructions and directives. An overarching lesson emerges: that disciplined execution in accordance with proven best practices is the greatest single contributor to a successful program. The Lessons Learned task team offers a sincere hope that the lessons presented herein will be helpful to the Exploration Systems Directorate in charting and executing their course. The success of the Directorate and of NASA in general depends on our collective ability to move forward without having to relearn the lessons of those who have gone before.

Van Laak, Jim↗

TU-CD-BRD-01: Making Incident Learning Practical and Useful: Challenges and Previous Experiences

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗

TU-CD-BRD-02: Henry Ford Hospital System Experience, with Focus On Motivating and Reviewing

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗

TU-CD-BRD-03: UCSD Experience, with Focus On Implementing Change

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗

TU-CD-BRD-04: UCLA Experience, with Focus On Developing Metrics and Using RO-ILS

It has long been standard practice in radiation oncology to report internally when a patient’s treatment has not gone as planned and to report events to regulatory agencies when legally required. Most potential errors are caught early and never affect the patient. Quality assurance steps routinely prevent errors from reaching the patient, and these “near misses” are much more frequent than treatment errors. A growing number of radiation oncology facilities have implemented incident learning systems to report and analyze both errors and near misses. Using the term “incident learning” instead of “event reporting” emphasizes the need to use these experiences to change the practice and make future errors less likely and promote an educational, non-punitive environment. There are challenges in making such a system practical and effective. Speakers from institutions of different sizes and practice environments will share their experiences on how to make such a system work and what benefits their clinics have accrued. Questions that will be addressed include: How to create a system that is easy for front line staff to access How to motivate staff to report How to promote the system as positive and educational and not punitive or demeaning How to organize the team for reviewing and responding to reports How to prioritize which reports to discuss in depth How not to dismiss the rest How to identify underlying causes How to design corrective actions and implement change How to develop useful statistics and analysis tools How to coordinate a departmental system with a larger risk management system How to do this without a dedicated quality manager Some speakers’ experience is with in-house systems and some will share experience with the AAPM/ASTRO national Radiation Oncology Incident Learning System (RO-ILS). Reports intended to be of value nationally need to be comprehensible to outsiders; examples of useful reports will be shown. There will be ample time set aside for audience members to contribute to the discussion. Learning Objectives: Learn how to promote the use of an incident learning system in a clinic. Learn how to convert “event reporting” into “incident learning”. See examples of practice changes that have come out of learning systems. Learn how the RO-ILS system can be used as a primary internal learning system. Learn how to create succinct, meaningful reports useful to outside readers. Gary Ezzell chairs the AAPM committee overseeing RO-ILS and has received an honorarium from ASTRO for working on the committee reviewing RO-ILS reports. Derek Brown is a director of http://TreatSafely.org . Brett Miller has previously received travel expenses and an honorarium from Varian. Phillip Beron has nothing to report.

60 APPLIED LIFE SCIENCES↗

Photonics of liquid-crystal structures: A review

The original results of studies of the electro-optical and laser effects which have been performed at the Laboratory of Liquid Crystals of the Institute of Crystallography, Russian Academy of Sciences, over the last few years are reviewed. Cholesteric liquid crystals as vivid representatives of photonic structures and their behavior in an electric field are considered in detail. The formation of higher harmonics in the periodic distribution of the director field in a helical liquid crystal structure and, correspondingly, the new (anharmonic) mode of electro-optical effects are discussed. Another group of studies is devoted to bistable light switching by an electric field in chiral nematics. Polarization diffraction gratings controlled by an electric field are also considered. The results of studies devoted to microlasers on various photonic structures with cholesteric and nematic liquid crystals are considered in detail. Particular attention is given to the new regime: leaky-mode lasing. Designs of liquid crystal light amplifiers and their polarization, field, and spectral characteristics are considered in the last section.

75 CONDENSED MATTER PHYSICS, SUPERCONDUCTIVITY AND↗

Legacy Depleted Uranium (DU) Discovered on TTR Lakebed (subsurface)(DOE Occurrence Report Final Notification)

Soil from an excavated test was being surveyed and fresh DU fragments removed so the soil could be returned to the excavation hole. Sandia RCTs discovered two locations where highly oxidized DU was present just below the undisturbed lake bed surface. The oxidized DU was removed for disposal as radioactive waste. Approximately one cubic foot of oxidized DU mixed with soil was removed. Line Manager, Sr. Manager and Acting Director were all notified of this event.

12 MANAGEMENT OF RADIOACTIVE AND NON-RADIOACTIVE W↗

JSC Director's Discretionary Fund 1992 Annual Report

Annual report of the Johnson Space Center Director's Discretionary Fund documenting effective use of resources. The $1,694,000 funding for FY92 was distributed among 27 projects. The projects are an overall aid to the NASA mission, as well as providing development opportunities for the science and engineering staff with eventual spinoff to commercial uses. Projects described include space-based medical research such as the use of stable isotopes of deuterium and oxygen to measure crew energy use and techniques for noninvasive motion sickness medication. Recycling essentials for space crew support is conducted in the Regenerative Life Support and the Hybrid Regenerative Water Recovery test beds. Two-phase fluid flow simulated under low-gravity conditions, hypervelocity particle impact on open mesh bumpers, and microcalorimetry to measure the long-term hydrazine/material compatibility were investigated. A patent application was made on a shape-memory-alloy release nut. Computer estimate of crew accommodations for advanced concepts was demonstrated. Training techniques were evaluated using multimedia and virtual environment. Upgrades of an electronic still camera provide high resolution images from orbit are presented.

Jenkins, Lyle↗

Urban Food Initiative

Shashi Buluswar, Berkeley Lab's Executive Director of the Institute for Globally Transformative Technologies (LIGTT) discusses the issue of urban food deserts and malnutrition in American inner cities.

54 ENVIRONMENTAL SCIENCES↗

Mechanical Actuation via Homeomorphic Transformations of Topological Solitons within Polymer Coatings

Abstract Topological solitons are currently under investigation for their exotic properties, especially in nonlinear physics, optics, and material sciences. However, challenges of robust generation and limited stability over time have hindered their practical uses. To address this issue, an approach is developed to form structured arrays of solitons in films of polymerizable liquid crystals. Their complex molecular architecture is preserved by in situ photopolymerization forming a stable liquid crystal network. Most excitingly, their properties are advanced to include responsiveness functions. When thermally actuated, these topological solitons mediate the reconfiguration of surface topographies. Complex shape changes occur depending on the intrinsic complex spatial distribution of the director, which may even lead to full shape inversion and topographical changes as high as ≈40% of the initial thickness. Conversely, the shape changes provide information on the initial director profile, which is consistent with the mathematical model. The soliton‐containing polymer coatings are applicable in multiple domains, ranging from tunable optics to haptics, and from shape‐coupled sensing systems to temperature‐coupled heat management.

36 MATERIALS SCIENCE↗