The impact of advanced technologies on treatment deviations in radiation treatment delivery

Technical note: Visual, rapid, scintillation point dosimetry for in vivo MV photon beam radiotherapy treatments

BACKGROUND

While careful planning and pre-treatment checks are performed to ensure patient safety during external beam radiation therapy (EBRT), inevitable daily variations mean that in vivo dosimetry (IVD) is the only way to attain the true delivered dose. Several countries outside the US require daily IVD for quality assurance. However, elsewhere, the manual labor and time considerations of traditional in vivo dosimeters may be preventing frequent use of IVD in the clinic.

PURPOSE

This study expands upon previous research using plastic scintillator discs for optical dosimetry for electron therapy treatments. We present the characterization of scintillator discs for in vivo x-ray dosimetry and describe additional considerations due to geometric complexities.

METHODS

Plastic scintillator discs were coated with reflective white paint on all sides but the front surface. An anti-reflective, matte coating was applied to the transparent face to minimize specular reflection. A time-gated iCMOS camera imaged the discs under various irradiation conditions. In post-processing, background-subtracted images of the scintillators were fit with Gaussian-convolved ellipses to extract several parameters, including integral output, and observation angle.

RESULTS

Dose linearity and x-ray energy independence were observed, consistent with ideal characteristics for a dosimeter. Dose measurements exhibited less than 5% variation for incident beam angles between 0° and 75° at the anterior surface and 0-60∘ $^\circ $ at the posterior surface for exit beam dosimetry. Varying the angle between the disc surface and the camera lens did not impact the integral output for the same dose up to 55°. Past this point, up to 75°, there is a sharp falloff in response; however, a correction can be used based on the detected width of the disc. The reproducibility of the integral output for a single disc is 2%, and combined with variations from the gantry angle, we report the accuracy of the proposed scintillator disc dosimeters as ±5.4%.

CONCLUSIONS

Plastic scintillator discs have characteristics that are well-suited for in vivo optical dosimetry for x-ray radiotherapy treatments. Unlike typical point dosimeters, there is no inherent readout time delay, and an optical recording of the measurement is saved after treatment for future reference. While several factors influence the integral output for the same dose, they have been quantified here and may be corrected in post-processing.

Comparison between the WHO-CFICPS and the PRISMA classification of safety-related events in a radiation oncology department

INTRODUCTION

Describing Safety-Related Events (SREs) in a radiotherapy (RT) department and comparing WHO-CFICPS (World Health Organization's Conceptual Framework For The International Classification For Patient Safety) and PRISMA (Prevention and Recovery Information System for Monitoring and Analysis) methods for classifying SREs.

METHODS

From February 2017 to October 2020, two Quality Managers (QMs) randomly classified 1173 SREs using 13 incident types of WHO-CFICPS. The same two QMs, reclassified the same SREs according to 20 PRISMA incident codes. Statistical analysis was performed to assess the association between the 13 incident types of WHO-CFICPS and the 20 PRISMA codes. The chi-squared and post-hoc tests using adjusted standardized residuals were applied to detect the association between the two systems.

RESULTS

There was a significant association between WHO-CFICPS incident types and PRISMA codes (P < 0.001). Ninety-two percent of all SREs were categorized using 4 of 13 WHO-CFICPS incident types including Clinical Process/Procedure (n = 448, 38.2%), Clinical Administration (n = 248, 21.1%), Documentation (n = 226, 19.2%) and Resources/Organizational Management (n = 15,613.3%). According to PRISMA classification, 14 of the 20 codes were used to describe the same SREs. PRISMA captured 41 Humans Skill Slips from 226 not better defined WHO-CFICPS Documentation Incidents, 38 Human Rule-based behaviour Qualification from not better defined 447 Clinical Process/Procedure and 40 Organization Management priority events from 156 not better defined WHO-CFICPS Resources/Organizational Management events (P < 0.001).

CONCLUSION

Although there was a significant association between WHO-CFICPS and PRISMA, The PRISMA method provides a more detailed insight into SREs compared to WHO-CFICPS in a RT department.

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period

INTRODUCTION

Advancements in technology and processes are designed to bring improvement. However, this is often achieved in parallel with increases in complexity, simultaneously presenting opportunities for new types of errors. This study aims to contextualise the impact of internal departmental changes upon radiation incidents and near misses recorded.

METHODS

A timeline of events and a comprehensive incident categorisation system were applied to all radiation incidents and near misses recorded at the Princess Alexandra Hospital Radiation Oncology department from 2003 to 2019, inclusive. Descriptive statistics were performed to identify the type and number of incidents reported during the time period in relation to potential changes within the department, with a focus on the implementation of an electronic environment.

RESULTS

Over the seventeen-year period, 157 incidents and 76 near misses were reported. The majority of incidents were classified as 'procedural' (78%), with 'treatment' being both the highest point of error and point of detection (49% and 85%, respectively). The largest number of incidents and near misses were reported in 2018 (n = 39) which was also a year that experienced the largest number of departmental changes (n = 16), including the move to a completely electronic planning process.

CONCLUSIONS

Changes within the department were followed by an increasing number of reported incidents. Proactive measures should be undertaken prior to the implementation of major changes within the department to aid in the minimisation of incident occurrence.

Failure mode and effect analysis for linear accelerator-based paraspinal stereotactic body radiotherapy

Introduction

Paraspinal stereotactic body radiotherapy (SBRT) involves risks of severe complications. We evaluated the safety of the paraspinal SBRT program in a large academic hospital by applying failure modes and effects analysis.

Methods

The analysis was conducted by a multidisciplinary committee (two therapists, one dosimetrist, four physicists, and two radiation oncologists). The paraspinal SBRT workflow was segmented into four phases (simulation, treatment planning, delivery, and machine quality assurance (QA)). Each phase was further divided into a sequence of sub‐processes. Potential failure modes (PFM) were identified from each subprocess and scored in terms of the frequency of occurrence, severity and detectability, and a risk priority number (RPN). High‐risk PFMs were identified based on RPN and were studied for root causes using fault tree analysis.

Results

Our paraspinal SBRT process was characterized by eight simulations, 11 treatment planning, nine delivery, and two machine QA sub‐processes. There were 18, 29, 19, and eight PFMs identified from simulation, planning, treatment, and machine QA, respectively. The median RPN of the PFMs was 62.9 for simulation, 68.3 for planning, 52.9 for delivery, and 22.0 for machine QA. The three PFMs with the highest RPN were: previous radiotherapy outside the institution is not accurately evaluated (RPN: 293.3), incorrect registration between diagnostic magnetic resonance imaging and simulation computed tomography causing incorrect contours (273.0), and undetected patient movement before ExacTrac baseline (217.8). Remedies to the high RPN failures were implemented, including staff education, standardized magnetic resonance imaging acquisition parameters, and an image fusion process, and additional QA on beam steering.

Conclusions

A paraspinal SBRT workflow in a large clinic was evaluated using a multidisciplinary and systematic risk analysis, which led to feasible solutions to key root causes. Treatment planning was a major source of PFMs that systematically affect the safety and quality of treatments. Accurate evaluation of external treatment records remains a challenge.

Common Error Pathways in CyberKnife™ Radiation Therapy

Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) may be considered “high risk” due to the high doses per fraction. We analyzed CyberKnife™ (CK) SRS and SBRT-related incidents that were prospectively reported to our in-house incident learning system (ILS) in order to identify severity, contributing factors, and common error pathways.

Material and Methods: From 2012 to 2019, 221 reported incidents related to the 4,569 CK fractions delivered (5.8%) were prospectively analyzed by our multi-professional Quality and Safety Committee with regard to severity, contributing factors, as well as the location where the incident occurred (tripped), where it was discovered (caught), and the safety barriers that were traversed (crossed) on the CK process map. Based on the particular step in the process map that incidents tripped, we categorized incidents into general error pathways.

Results: There were 205 severity grade 1–2 (did not reach patient or no clinical impact), 11 grade 3 (clinical impact unlikely), 5 grade 4 (altered the intended treatment), and 0 grade 5–6 (life-threatening or death) incidents, with human performance being the most common contributing factor (79% of incidents). Incidents most commonly tripped near the time when the practitioner requested CK simulation (e.g., pre-CK simulation fiducial marker placement) and most commonly caught during the physics pre-treatment checklist. The four general error pathways included pre-authorization, billing, and scheduling issues (n= 119); plan quality (n= 30); administration of IV contrast during simulation or pre-medications during treatment (n= 22); and image guidance (n= 12).

Conclusion: Most CK incidents led to little or no patient harm and most were related to billing and scheduling issues. Suboptimal human performance appeared to be the most common contributing factor to CK incidents. Additional study is warranted to develop and share best practices to reduce incidents to further improve patient safety.

Enhancing value of quality assurance rounds in improving radiotherapy management: a retrospective analysis from King Hussein Cancer Center in Jordan

PURPOSE

The quality assurance (QA) chart rounds are multidisciplinary meetings to review radiation therapy (RT) treatment plans. This study focus on describing the changes in RT management based on QA round reviews in a single institution.

MATERIALS AND METHODS

After 9 full years of implementation, a retrospective review of all patients whose charts passed through departmental QA chart rounds from 2007 to 2015. The reviewed cases were presented for RT plan review; subcategorized based on decision in QA rounds into: approved, minor modifications or major modifications. Major modification defined as any substantial change which required patient re-simulation or re-planning prior to commencement of RT. Minor modification included treatment plan changes which didn't necessarily require RT re-planning.

RESULTS

Overall 7,149 RT treatment plans for different anatomical sites were reviewed at QA rounds. From these treatment plans, 6,654 (93%) were approved, 144 (2%) required minor modifications, while 351 (5%) required major modifications. Major modification included changes in: selected RT dose (96/351, 27%), target volume definition (127/351, 36%), organs-at-risk contouring (10/351, 3%), dose volume objectives/constraints criteria (90/351, 26%), and intent of treatment (28/351, 8%). The RT plans which required major modification according to the tumor subtype were as follows: head and neck (104/904, 12%), thoracic (12/199, 6%), gastrointestinal (33/687,5%), skin (5/106, 5%), genitourinary (16/359, 4%), breast (104/2387, 4%), central nervous system (36/846, 4%), sarcoma (11/277, 4%), pediatric (7/251, 3%), lymphoma (10/423, 2%), gynecological tumors (2/359, 1%), and others (11/351, 3%).

CONCLUSION

Multi-disciplinary standardized QA chart rounds provide a comprehensive and an influential method on RT plans and/ or treatment decisions.

A Usability Study of 3 Radiotherapy Systems: A Comparative Evaluation Based on Expert Evaluation and User Experience

BACKGROUND The complex user interface design of radiotherapy treatment delivery systems can lead to use error and patient harm. In this study, we present the results of a comparison of 3 radiotherapy treatment delivery systems now used in China. MATERIAL AND METHODS We conducted a comprehensive usability study of 3 radiotherapy treatment delivery systems. Expert evaluation was performed through heuristic evaluation with 3 human-factors experts and 1 experienced radiation therapist for each system. User experience was assessed through perceived system usability and workload, using the National Aeronautics and Space Administration Task Load Index and the Post-Study System Usability Questionnaire. RESULTS For the expert evaluation, 47 usability problems were identified for Varian Trilogy, 75 for Elekta Precise, and 37 for Shinva XHA600E. Most problems were classified as major and minor usability problems, and were found in the process of patient setup and setup verification. For the user experience, radiation therapists presented a lower workload for Varian Trilogy compared to Elekta Precise (P<0.01) and Shinva XHA600E (P<0.01), and a lower workload for Elekta Precise compared to Shinva XHA600E (P=0.020). Radiation therapists perceived a higher system usability for Varian Trilogy compared to Shinva XHA600E (P<0.01), and a higher system usability for Elekta Precise compared to Shinva XHA600E (P<0.01). CONCLUSIONS This research provides valuable data on how 3 radiotherapy treatment delivery systems compare. The results of this study may be useful for hospital equipment procurement decisions, and designing next-generation products to improve patient safety.

Radiation oncology resident training in patient safety and quality improvement: a national survey of residency program directors

Background

Physicians and physicists are expected to contribute to patient safety and quality improvement (QI) in Radiation Oncology (RO), but prior studies suggest that training for this may be inadequate. RO and medical physics (MP) program directors (PDs) were surveyed to better understand the current patient safety/QI training in their residency programs.

Methods

PDs were surveyed via email in January 2017. Survey questions inquired about current training, curriculum elements, and barriers to development and/or improvement of safety and QI training.

Results

Eighty-nine RO PDs and 84 MP PDs were surveyed, and 21 RO PDs (28%) and 31 MP PDs (37%) responded. Both RO and MP PDs had favorable opinions of current safety and QI training, and used a range of resources for program development, especially safety and QI publications. Various curriculum elements were reported. Curriculum elements used by RO and MP PDs were similar, except RO were more likely than MP PDs to implement morbidity and mortality (M&M) conference (72% vs. 45%, p < 0.05). RO and MP PDs similarly cited various barriers, but RO PDs were more likely to cite lack of experience than MP PDs (40% vs. 16%, p < 0.05). PDs responded similarly independent of whether they reported using a departmental incident learning system (ILS) or not.

Conclusions

PDs view patient safety/QI as an important part of resident education. Most PDs agreed that residents are adequately exposed to patient safety/QI and prepared to meet the patient safety/QI expectations of clinical practice. This conflicts with other independent studies that indicate a majority of residents feel their patient safety/QI training is inadequate and lacks formal exposure to QI tools.

Electronic supplementary material

The online version of this article (10.1186/s13014-018-1128-5) contains supplementary material, which is available to authorized users.

Consensus Recommendations for Developing IQ Script Enabled Radiation Oncology Care Plans in the MOSAIQ Oncology Information System

BACKGROUND

IQ script enabled radiation oncology (RO) Care Plans are a unique functionality of the MOSAIQ oncology information system and enables standardization of clinical workflow via predefined order sets, strategic launching of assessment forms, and automated forwarding of clinical tasks. However, the development of RO Care Plans is center-specific and must be adapted to each center's clinical workflow. To our knowledge, little to no guidelines exist for RO Care Plan implementation. This article is a collaborative article from 5 different centers of varying sizes and adoption stage that provides consensus strategies for RO Care Plan development.

METHODS

In 2016, 5 different centers of varying sizes and adoption stages met to develop strategies for RO Care Plan development. Before the meeting, an initial draft was circulated to all participating centers for feedback and incorporated into a refined document. The refined recommendations underwent a formal, 3-stage consensus process mediated by a radiation therapist to arrive at the final document.

RESULTS

Overall, 17 recommendations were provided that focused on 7 areas of Care Plan development: (1) predevelopment planning, (2) current-state RO workflow evaluation, (3) future-state RO integration planning, (4) Care Plan authoring, (5) pre-implementation, (6) implementation, and (7) post-implementation evaluation and review.

CONCLUSIONS

Care Plan development is a center-specific process, and the resulting recommendations provide a blueprint for a broad range of cancer centers for implementing Care Plans, or similar oncology information system modules, into their clinical processes.

Use of the AAPM Safety Profile Assessment Tool to Evaluate the Change in Safety Culture After Implementing the RABBIT Prospective Risk Management System

Purpose

Hospitals traditionally focus on reactive risk management such as incident reporting, but prospective risk management systems such as failure modes and effects analysis are also important tools to reduce risks and improve the safety culture. In 2015, the St George Cancer Care Centre (STGCCC) developed a multidisciplinary risk-based system for the safe and effective implementation of new technologies and techniques, using risk and benefit balance impact templates (RABBIT) developed in-house. The purpose of this study was to determine whether risk management and the safety culture in radiation oncology were perceived to have improved since the introduction of the RABBIT system.

Methods and materials

In 2017, radiation oncologists, radiation therapists, and medical physicists were asked to rate the department before and after the introduction of the RABBIT using questions from the American Association of Physicists in Medicine Safety Profile Assessment (SPA) tool. Answers relating to the implementation of new technology/techniques are presented.

Results

STGCCC staff confirmed that the RABBIT system has improved the implementation of new technology/techniques, with an average SPA question score improvement from 3.9 to 4.4 (of 5.0). This compares favorably with the SPA world average of 3.5 (October 2017). The improvement is attributed to risks being formally identified and managed and adequate staff training being mandatory and systematic. There were also perceived improvements in teamwork, probably because the introduction of structured multidisciplinary teams resulted in each group having a better understanding of the workflows and priorities of the other groups.

Conclusions

This study shows that prospective risk management at STGCCC has improved the perceived quality of the implementation of new technology/techniques. The RABBIT is a simple and effective method for achieving this improvement in safety culture. The American Association of Physicists in Medicine SPA is a valuable tool for assessing the success of quality initiatives and identifying opportunities for further improvement.

Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

AIM

To develop and apply a clinical incident taxonomy for radiation therapy.

BACKGROUND

Capturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability.

METHODS AND MATERIALS

A clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care. The taxonomy was applied to all clinical incidents occurring at three integrated cancer centres for the years 2011-2015. Incidents were managed locally, audited and feedback disseminated to all centres.

RESULTS

Across the five years the total incident rate (per 100 courses) was 8.54; the radiotherapy-specific coded rate was 6.71. The rate of true adverse events (unintended treatment and potential patient harm) was 1.06. Adverse events, where no harm was identified, occurred at a rate of 2.76 per 100 courses. Despite workload increases, overall and actual rates both exhibited downward trends over the 5-year period. The taxonomy captured previously unidentified quality assurance failures; centre-specific issues that contributed to variations in incident trends were also identified.

CONCLUSIONS

The application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.

Incident learning in radiation oncology: A review

Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.

4π plan optimization for cortical-sparing brain radiotherapy

BACKGROUND AND PURPOSE

Incidental irradiation of normal brain tissue during radiotherapy is linked to cognitive decline, and may be mediated by damage to healthy cortex. Non-coplanar techniques may be used for cortical sparing. We compared normal brain sparing and probability of cortical atrophy using 4π radiation therapy planning vs. standard fixed gantry intensity-modulated radiotherapy (IMRT).

MATERIAL AND METHODS

Plans from previously irradiated brain tumor patients ("original IMRT", n = 13) were re-planned to spare cortex using both 4π optimization ("4π") and IMRT optimization ("optimized IMRT"). Homogeneity index (HI), gradient measure, doses to cortex and white matter (excluding tumor), brainstem, optics, and hippocampus were compared with matching PTV coverage. Probability of three grades of post-treatment cortical atrophy was modeled based on previously established dose response curves.

RESULTS

With matching PTV coverage, 4π significantly improved HI by 27% (p = 0.005) and gradient measure by 8% (p = 0.001) compared with optimized IMRT. 4π optimization reduced mean and equivalent uniform doses (EUD) to all standard OARs, with 14-15% reduction in hippocampal EUD (p ≤ 0.003) compared with the other two plans. 4π significantly reduced dose to fractional cortical volumes (V50, V40 and V30) compared with the original IMRT plans, and reduced cortical V30 by 7% (p = 0.008) compared with optimized IMRT. White matter EUD, mean dose, and fractional volumes V50, V40 and V30 were also significantly lower with 4π (p ≤ 0.001). With 4π, probability of grade 1, 2 and 3 cortical atrophy decreased by 12%, 21% and 26% compared with original IMRT and by 8%, 14% and 3% compared with optimized IMRT, respectively (p ≤ 0.001).

CONCLUSIONS

4π radiotherapy significantly improved cortical sparing and reduced doses to standard brain OARs, white matter, and the hippocampus. This was achieved with superior PTV dose homogeneity. Such sparing could reduce the probability of cortical atrophy that may lead to cognitive decline.

Identifying Factors and Root Causes Associated With Near-Miss or Safety Incidents in Patients Treated With Radiotherapy: A Case-Control Analysis

Purpose:

To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing radiotherapy and identify common root causes of NMSIs and their relationship with incident severity.

Methods:

We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with an NMSI (n = 200; incident group) and a similar group of control patients (n = 200) matched in time, without an NMSI. A root cause and incident severity were determined for each NMSI. Univariable and multivariable analyses were performed to determine which specific factors were contributing to NMSIs. Multivariable logistic regression was used to determine root causes of NMSIs and their relationship with incident severity.

Results:

NMSIs were associated with the following factors: head and neck sites (odds ratio [OR], 5.2; P = .01), image-guided intensity-modulated radiotherapy (OR, 3; P = .009), daily imaging (OR, 7; P < .001), and tumors staged as T2 (OR, 3.3; P = .004). Documentation and scheduling errors were the most common root causes (29%). Communication errors were more likely to affect patients ( P < .001), and technical treatment delivery errors were most associated with a higher severity score ( P = .005).

Conclusion:

Several treatment- and disease-specific factors were found to be associated with an NMSI. Overall, our results suggest that complexity (eg, head and neck, image-guided intensity-modulated radiotherapy, and daily imaging) might be a contributing factor for an NMSI. This promotes an idea of developing a more dedicated and robust quality assurance system for complex cases and highlights the importance of a strong reporting system to support a safety culture.

Improving efficiency and safety in external beam radiation therapy treatment delivery using a Kaizen approach

INTRODUCTION

Modern external beam radiation therapy treatment delivery processes potentially increase the number of tasks to be performed by therapists and thus opportunities for errors, yet the need to treat a large number of patients daily requires a balanced allocation of time per treatment slot. The goal of this work was to streamline the underlying workflow in such time-interval constrained processes to enhance both execution efficiency and active safety surveillance using a Kaizen approach.

METHODS AND MATERIALS

A Kaizen project was initiated by mapping the workflow within each treatment slot for 3 Varian TrueBeam linear accelerators. More than 90 steps were identified, and average execution times for each were measured. The time-consuming steps were stratified into a 2 × 2 matrix arranged by potential workflow improvement versus the level of corrective effort required. A work plan was created to launch initiatives with high potential for workflow improvement but modest effort to implement. Time spent on safety surveillance and average durations of treatment slots were used to assess corresponding workflow improvements.

RESULTS

Three initiatives were implemented to mitigate unnecessary therapist motion, overprocessing of data, and wait time for data transfer defects, respectively. A fourth initiative was implemented to make the division of labor by treating therapists as well as peer review more explicit. The average duration of treatment slots reduced by 6.7% in the 9 months following implementation of the initiatives (P = .001). A reduction of 21% in duration of treatment slots was observed on 1 of the machines (P < .001). Time spent on safety reviews remained the same (20% of the allocated interval), but the peer review component increased.

CONCLUSIONS

The Kaizen approach has the potential to improve operational efficiency and safety with quick turnaround in radiation therapy practice by addressing non-value-adding steps characteristic of individual department workflows. Higher effort opportunities are identified to guide continual downstream quality improvements.

Implementing and integrating a radiation oncology information system as a pedagogical tool for undergraduate radiation therapy training

Purpose

Radiation oncology information systems (OIS) play a crucial role in radiation therapy by ensuring accurate and safe delivery of treatment. A MOSAIQ OIS system is currently used to support undergraduate radiation therapist training at Queensland University of Technology. This review addresses the rationale for implementation and integration in teaching environments and explores the pedagogical benefits supported by educational theory.

Discussion

A review of MOSAIQ functionality shows potential to transform learning through the development of authentic and engaging learning tasks. It provides students with an opportunity to learn two-dimensional image matching through the use of digitally reconstructed radiographs and electronic portal images as well as three-dimensional image matching using computed tomography (CBCT) data in a safe learning environment without clinical time pressures. In addition, this provides the students with knowledge of quality assurance (QA) checks through the verification of treatment parameters and the transfer of information from the planning system to the treatment units. However, there are several potential challenges and practical considerations that need to be overcome.

Conclusion

The application of MOSAIQ OIS could potentially transform teaching and learning strategies for student radiation therapists. Increased knowledge and hands-on skills at undergraduate levels in areas such as image matching and QA can be powerful tools to drive the standards of practice a step further.

Nature of Medical Malpractice Claims Against Radiation Oncologists

PURPOSE

To examine characteristics of medical malpractice claims involving radiation oncologists closed during a 10-year period.

METHODS AND MATERIALS

Malpractice claims filed against radiation oncologists from 2003 to 2012 collected by a nationwide liability insurance trade association were analyzed. Outcomes included the nature of claims and indemnity payments, including associated presenting diagnoses, procedures, alleged medical errors, and injury severity. We compared the likelihood of a claim resulting in payment in relation to injury severity categories (death as referent) using binomial logistic regression.

RESULTS

There were 362 closed claims involving radiation oncology, 102 (28%) of which were paid, resulting in $38 million in indemnity payments. The most common alleged errors included "improper performance" (38% of closed claims, 18% were paid; 29% [$11 million] of total indemnity), "errors in diagnosis" (25% of closed claims, 46% were paid; 44% [$17 million] of total indemnity), and "no medical misadventure" (14% of closed claims, 8% were paid; less than 1% [$148,000] of total indemnity). Another physician was named in 32% of claims, and consent issues/breach of contract were cited in 18%. Claims for injury resulting in death represented 39% of closed claims and 25% of total indemnity. "Improper performance" was the primary alleged error associated with injury resulting in death. Compared with claims involving death, major temporary injury (odds ratio [OR] 2.8, 95% confidence interval [CI] 1.29-5.85, P=.009), significant permanent injury (OR 3.1, 95% CI 1.48-6.46, P=.003), and major permanent injury (OR 5.5, 95% CI 1.89-16.15, P=.002) had a higher likelihood of a claim resulting in indemnity payment.

CONCLUSIONS

Improper performance was the most common alleged malpractice error. Claims involving significant or major injury were more likely to be paid than those involving death. Insights into the nature of liability claims against radiation oncologists may help direct efforts to improve quality of care and minimize the risk of being sued.

The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management

The increasing complexity of modern radiation therapy planning and delivery challenges traditional prescriptive quality management (QM) methods, such as many of those included in guidelines published by organizations such as the AAPM, ASTRO, ACR, ESTRO, and IAEA. These prescriptive guidelines have traditionally focused on monitoring all aspects of the functional performance of radiotherapy (RT) equipment by comparing parameters against tolerances set at strict but achievable values. Many errors that occur in radiation oncology are not due to failures in devices and software; rather they are failures in workflow and process. A systematic understanding of the likelihood and clinical impact of possible failures throughout a course of radiotherapy is needed to direct limit QM resources efficiently to produce maximum safety and quality of patient care. Task Group 100 of the AAPM has taken a broad view of these issues and has developed a framework for designing QM activities, based on estimates of the probability of identified failures and their clinical outcome through the RT planning and delivery process. The Task Group has chosen a specific radiotherapy process required for "intensity modulated radiation therapy (IMRT)" as a case study. The goal of this work is to apply modern risk-based analysis techniques to this complex RT process in order to demonstrate to the RT community that such techniques may help identify more effective and efficient ways to enhance the safety and quality of our treatment processes. The task group generated by consensus an example quality management program strategy for the IMRT process performed at the institution of one of the authors. This report describes the methodology and nomenclature developed, presents the process maps, FMEAs, fault trees, and QM programs developed, and makes suggestions on how this information could be used in the clinic. The development and implementation of risk-assessment techniques will make radiation therapy safer and more efficient.

Ten-year trends in safe radiation therapy delivery and results of a radiation therapy quality assurance intervention

PURPOSE

This study reviews our institutional error data and assesses the effectiveness of a policy implemented January 1, 2011, as a "no rushed treatment" initiative to avoid universal, large-scale replanning for all patients in the event that a treatment unit is down for ≤1 day.

METHODS AND MATERIALS

Radiation error data between January 1, 2004, and December 31, 2014, were reviewed to determine absolute delivery error rates. Variables were compared (using a χ(2) or Fisher exact test) before and after the policy change, including planning versus delivery error status and differences in error type. We also evaluated time of day in relation to therapist shift change, deviation from scheduled time, and weekend treatment as predictors of error using a test of proportions or χ(2) test.

RESULTS

Treatment delivery error rate over the entire period was 0.18% per fraction; the rate before intervention was 0.24% and after was 0.08%, P < .001. For the 5 years for which detailed records were available (2010-2014), 109 delivery errors were reported. Delivery error rate was 0.09%; before intervention 0.15% versus after, 0.08% (P = .005) and 94% were level 1 errors. Fifty-six percent were primary planning errors and 44% were primary delivery errors. Before intervention, large-scale replanning occurred 18 times/year versus 4.5/year after, with 21% versus 12% of errors directly attributable to large-scale replanning. Fourteen error reports specifically implicated a rushed environment as causal. There was no significant difference in error rate based on time of day (P = .631). Error rates were higher for weekend simulation and treatments, 1.3% versus 0.09% per fraction (P < .001).

CONCLUSIONS

Delivery error rates at our institution were similar compared with published series from other academic institutions. A significant improvement in delivery error rate was appreciated after implementation of a "no rushed treatment" initiative. A significantly higher error rate for weekend treatments was noted, warranting consideration of additional quality assurance measures.

Evaluating the Impact of In Vivo EPID Dosimetry on Intensity-Modulated Radiation Therapy Treatment Delivery Workflow: A Stakeholder Perspective

INTRODUCTION

In vivo electronic portal imaging device (EPID) dosimetry is an advanced imaging technique that can obtain patient-specific dose data for quality assurance purposes. However, clinical integration of this technique remains a challenge. This study evaluates the impact of implementing an in vivo EPID technique into the treatment delivery workflow for head and neck cancer (HNC) patients in a large cancer centre setting.

MATERIALS/METHODS

Intensity-modulated radiation therapy treatment delivery was simulated on a phantom for 10 HNC cases with and without in vivo EPID dosimetry. Investigators performed the EPID technique by using a preliminary protocol written by medical physicists. Process maps were created to illustrate changes in treatment delivery workflow.

RESULTS

Treatment delivery times increased by an average of 2.34 minutes (P = .0006) when the EPID technique was used. Factors that increased treatment times included the time for storing captured EPID data, adjustment of the imaging panel position as a function of field size, and an inability to use automatic field sequencing when acquiring images.

CONCLUSIONS

The involvement of stakeholders in protocol development allows for the identification of usability issues and staff training needs. Findings from this study have identified limitations of the in vivo EPID technique that may negatively impact treatment delivery workflow. Efficiencies within in vivo EPID dosimetry systems can be improved by enabling automatic field sequencing with automatic image-saving capabilities.

Value: a framework for radiation oncology

In the current health care system, high costs without proportional improvements in quality or outcome have prompted widespread calls for change in how we deliver and pay for care. Value-based health care delivery models have been proposed. Multiple impediments exist to achieving value, including misaligned patient and provider incentives, information asymmetries, convoluted and opaque cost structures, and cultural attitudes toward cancer treatment. Radiation oncology as a specialty has recently become a focus of the value discussion. Escalating costs secondary to rapidly evolving technologies, safety breaches, and variable, nonstandardized structures and processes of delivering care have garnered attention. In response, we present a framework for the value discussion in radiation oncology and identify approaches for attaining value, including economic and structural models, process improvements, outcome measurement, and cost assessment.

Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator

PURPOSE

The aim of this study was to analyze the application of the failure modes and effects analysis (FMEA) to intracranial stereotactic radiation surgery (SRS) by linear accelerator in order to identify the potential failure modes in the process tree and adopt appropriate safety measures to prevent adverse events (AEs) and near-misses, thus improving the process quality.

METHODS AND MATERIALS

A working group was set up to perform FMEA for intracranial SRS in the framework of a quality assurance program. FMEA was performed in 4 consecutive tasks: (1) creation of a visual map of the process; (2) identification of possible failure modes; (3) assignment of a risk probability number (RPN) to each failure mode based on tabulated scores of severity, frequency of occurrence and detectability; and (4) identification of preventive measures to minimize the risk of occurrence.

RESULTS

The whole SRS procedure was subdivided into 73 single steps; 116 total possible failure modes were identified and a score of severity, occurrence, and detectability was assigned to each. Based on these scores, RPN was calculated for each failure mode thus obtaining values from 1 to 180. In our analysis, 112/116 (96.6%) RPN values were <60, 2 (1.7%) between 60 and 125 (63, 70), and 2 (1.7%) >125 (135, 180). The 2 highest RPN scores were assigned to the risk of using the wrong collimator's size and incorrect coordinates on the laser target localizer frame.

CONCLUSION

Failure modes and effects analysis is a simple and practical proactive tool for systematic analysis of risks in radiation therapy. In our experience of SRS, FMEA led to the adoption of major changes in various steps of the SRS procedure.

Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice.

The effect of failure mode and effect analysis on reducing percutaneous coronary intervention hospital door-to-balloon time and mortality in ST segment elevation myocardial infarction

BACKGROUND

Door-to-balloon (D2B) time is an important factor in the outcome of ST segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention. We aimed to use failure mode and effect analysis to reduce the D2B time for patients with STEMI and to improve clinical outcomes.

METHODS

There were three stages in this study. In Stage 0, data collected from 2005-2006 was used to identify failures in the process, and during Stage 2 (2007) and Stage 3 (2008) the efficacy of intrahospital and interhospital strategies to reduce the D2B time were evaluated. This study enrolled 385 patients; 86 from 2005-2006; 80 in 2007; and 219 in 2008.

RESULTS

By making improvements in these steps, the median D2B time was reduced from 146 min to 32 min for all patients. The proportion of patients with a D2B time of <90 min significantly increased from Stage 0 to Stage 1 and from Stage 1 to Stage 2, for all patients as well as for the non-transferred and transferred subgroups of patients (all p values <0.0001). For non-transferred patients, only reinfarction-free survival showed significant difference among the three stages (p=0.0225), and for transferred patients, only overall survival showed significant difference among the three stages (p=0.0322). Cox's proportional hazards regression analysis showed Stage 2 was associated with a lower risk of reinfarction and mortality compared with Stage 0.

CONCLUSIONS

This study found that failure mode and effect analysis is a powerful method for identifying weaknesses in D2B processes and evaluating strategies to reduce the D2B time.

Impact of complexity and computer control on errors in radiation therapy

A number of recent publications in both the lay and scientific press have described major errors in patient radiation treatments, and this publicity has galvanised much work to address and mitigate potential safety issues throughout the radiation therapy planning and delivery process. The complexity of modern radiotherapy techniques and equipment, including computer-controlled treatment machines and treatment management systems, as well as sophisticated treatment techniques that involve intensity-modulated radiation therapy, image-guided radiation therapy, stereotactic body radiation therapy, volumetric modulated arc therapy, respiratory gating, and others, leads to concern about safety issues related to that complexity. This article illustrates the relationship between complexity and computer control, and various safety problems and errors that have been reported, and describes studies that address the issue of these modern techniques and whether their complexity does, in fact, result in more errors or safety-related problems. Clinical implications of these results are discussed, as are some of the ways in which the field should respond to the ongoing concerns about errors and complexity in radiation therapy.

Quality assessment in oncology

The movement to improve healthcare quality has led to a need for carefully designed quality indicators that accurately reflect the quality of care. Many different measures have been proposed and continue to be developed by governmental agencies and accrediting bodies. However, given the inherent differences in the delivery of care among medical specialties, the same indicators will not be valid across all of them. Specifically, oncology is a field in which it can be difficult to develop quality indicators, because the effectiveness of an oncologic intervention is often not immediately apparent, and the multidisciplinary nature of the field necessarily involves many different specialties. Existing and emerging comparative effectiveness data are helping to guide evidence-based practice, and the increasing availability of these data provides the opportunity to identify key structure and process measures that predict for quality outcomes. The increasing emphasis on quality and efficiency will continue to compel the medical profession to identify appropriate quality measures to facilitate quality improvement efforts and to guide accreditation, credentialing, and reimbursement. Given the wide-reaching implications of quality metrics, it is essential that they be developed and implemented with scientific rigor. The aims of the present report were to review the current state of quality assessment in oncology, identify existing indicators with the best evidence to support their implementation, and propose a framework for identifying and refining measures most indicative of true quality in oncologic care.

Radiation oncology information systems and clinical practice compatibility: Workflow evaluation and comprehensive assessment

PURPOSE

To map the level of clinical practice compatibility with a radiation oncology information system (ROIS) through a workflow- and clinical process-based method aimed at optimizing the safety, efficacy, and efficiency of patient care; to improve the understanding of the critical relationship between the clinical practice and ROIS.

METHODS AND MATERIALS

Clinic-specific workflow and infrastructure were classified into clinical processes, information management, and technological innovation integration. Clinical information systems-information technology infrastructure and process maps were generated by a team of experts, representing clinical constituents. These maps served as the basis for evaluating connectivity and process flow and to guide the development of a quantitative survey where all clinical tasks and subprocesses were ranked according to importance in patient care and scored by the team of experts for performance. Process maps and survey output were used to measure ROIS compatibility with the practice and to guide practice improvement.

RESULTS

Practice-specific process and infrastructure maps were generated. The developed survey was applied and results indicate a range of ROIS compatibility with clinical workflow and infrastructure. Survey results combined with experiential feedback provided specific prioritized guidance to improve both ROIS performance and clinic-specific processes and infrastructure.

CONCLUSIONS

This work provides a systematic and customizable tool to understand and evaluate clinical information and workflow and its compatibility with a given ROIS. The analysis provides insight into workflow improvements and information systems and information technology infrastructure limitations. Participating in such a process provides the entire team with a deeper understanding of the critical relationship between the clinical practice and the ROIS.

US Food and Drug Administration Regulation of Medical Devices and Radiation Oncology: Can Reform Improve Safety?

Although radiation therapy is highly safe and effective in treating cancer, recent reports of dangerous radiation-related errors have focused a national spotlight on the field of radiation oncology and, more specifically, on the rapidly evolving and complex nature of radiation devices and how they are regulated. The purpose of this review is to explore the issues involved in medical device regulation in radiation oncology. We start with a general review of federal medical device regulation, including explanations of the legal and regulatory framework, and then discuss issues specific to radiation oncology with real-world examples. We also provide our thoughts on potential solutions and reforms to the current system, including better reporting of radiation-related errors in a centralized database, well-defined criteria for establishing substantial equivalence of a new device, and standard postmarket surveillance of radiation devices. Modern radiation therapy is a powerful tool that can help cure many patients' cancers and alleviate others' suffering with limited adverse effects. We must ensure that this promise is never compromised by avoidable mistakes.

Safety strategies in an academic radiation oncology department and recommendations for action

BACKGROUND

Safety initiatives in the United States continue to work on providing guidance as to how the average practitioner might make patients safer in the face of the complex process by which radiation therapy (RT), an essential treatment used in the management of many patients with cancer, is prepared and delivered. Quality control measures can uncover certain specific errors such as machine dose miscalibration or misalignments of the patient in the radiation treatment beam. However, they are less effective at uncovering less common errors that can occur anywhere along the treatment planning and delivery process, and even when the process is functioning as intended, errors still occur. PRIORITIZING RISKS AND IMPLEMENTING RISK-REDUCTION STRATEGIES: Activities undertaken at the radiation oncology department at the Johns Hopkins Hospital (Baltimore) include Failure Mode and Effects Analysis (FMEA), risk-reduction interventions, and voluntary error and near-miss reporting systems. A visual process map portrayed 269 RT steps occurring among four subprocesses-including consult, simulation, treatment planning, and treatment delivery. Two FMEAs revealed 127 and 159 possible failure modes, respectively. Risk-reduction interventions for 15 "top-ranked" failure modes were implemented. Since the error and near-miss reporting system's implementation in the department in 2007, 253 events have been logged. However, the system may be insufficient for radiation oncology, for which a greater level of practice-specific information is required to fully understand each event.

CONCLUSIONS

The "basic science" of radiation treatment has received considerable support and attention in developing novel therapies to benefit patients. The time has come to apply the same focus and resources to ensuring that patients safely receive the maximal benefits possible.