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Bonaparte I, Fragnoli F, Gregucci F, Carbonara R, Di Guglielmo FC, Surgo A, Davì V, Caliandro M, Sanfrancesco G, De Pascali C, Aga A, Indellicati C, Parabita R, Cuscito R, Cardetta P, Laricchia M, Antonicelli M, Ciocia A, Curci D, Guida P, Ciliberti MP, Fiorentino A. Improving Quality Assurance in a Radiation Oncology Using ARIA Visual Care Path. J Pers Med 2024; 14:416. [PMID: 38673043 PMCID: PMC11051245 DOI: 10.3390/jpm14040416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/07/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
PURPOSE Errors and incidents may occur at any point within radiotherapy (RT). The aim of the present retrospective analysis is to evaluate the impact of a customized ARIA Visual Care Path (VCP) on quality assurance (QA) for the RT process. MATERIALS AND METHODS The ARIA VCP was implemented in June 2019. The following tasks were customized and independently verified (by independent checks from radiation oncologists, medical physics, and radiation therapists): simulation, treatment planning, treatment start verification, and treatment completion. A retrospective analysis of 105 random and unselected patients was performed, and 945 tasks were reviewed. Patients' reports were categorized based on treatment years period: 2019-2020 (A); 2021 (B); and 2022-2023 (C). The QA metrics included data for timeliness of task completion and data for minor and major incidents. The major incidents were defined as incorrect prescriptions of RT dose, the use of different immobilization systems during RT compared to the simulation, the absence of surface-guided RT data for patients' positioning, incorrect dosimetric QA for treatment plans, and failure to complete RT as originally planned. A sample size of approximately 100 was able to obtain an upper limit of 95% confidence interval below 5-10% in the case of zero or one major incident. RESULTS From June 2019 to December 2023, 5300 patients were treated in our RT department, an average of 1300 patients per year. For the purpose of this analysis, one hundred and five patients were chosen for the study and were subsequently evaluated. All RT staff achieved a 100% compliance rate in the ARIA VCP timely completion. A total of 36 patients were treated in Period A, 34 in Period B, and 35 in Period C. No major incidents were identified, demonstrating a major incident rate of 0.0% (95% CI 0.0-3.5%). A total of 26 out of 945 analyzed tasks (3.8%) were reported as minor incidents: absence of positioning photo in 32 cases, lack of patients' photo, and absence of plan documents in 4 cases. When comparing periods, incidents were statistically less frequent in Period C. CONCLUSIONS Although the present analysis has some limitations, its outcomes demonstrated that software for the RT workflow, which is fully integrated with both the record-and-verify and treatment planning systems, can effectively manage the patient's care path. Implementing the ARIA VCP improved the efficiency of the RT care path workflow, reducing the risk of major and minor incidents.
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Affiliation(s)
- Ilaria Bonaparte
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Federica Fragnoli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Fabiana Gregucci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Roberta Carbonara
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Fiorella Cristina Di Guglielmo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Alessia Surgo
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Valerio Davì
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Morena Caliandro
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Giuseppe Sanfrancesco
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Christian De Pascali
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Alberto Aga
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Chiara Indellicati
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Rosalinda Parabita
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Rosilda Cuscito
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Pietro Cardetta
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Maurizio Laricchia
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Michele Antonicelli
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Annarita Ciocia
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Domenico Curci
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Pietro Guida
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Maria Paola Ciliberti
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
| | - Alba Fiorentino
- Department of Radiation Oncology, Miulli General Regional Hospital, 70021 Bari, Italy; (I.B.); (F.F.); (F.G.); (R.C.); (F.C.D.G.); (A.S.); (V.D.); (M.C.); (G.S.); (A.A.); (C.I.); (R.P.); (R.C.); (P.C.); (M.L.); (M.A.); (A.C.); (D.C.); (P.G.); (M.P.C.)
- Department of Medicine and Surgery, LUM University, 70010 Bari, Italy
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Rajurkar S, Verma T, Mishra SP, Bhatt MLB. Novel Artificial Intelligence Tool for Real-time Patient Identification to Prevent Misidentification in Health Care. J Med Phys 2024; 49:41-48. [PMID: 38828072 PMCID: PMC11141754 DOI: 10.4103/jmp.jmp_106_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 06/05/2024] Open
Abstract
Purpose Errors in the identification of true patients in a health-care facility may result in the wrong dose or dosage being given to the wrong patient at the wrong site during radiotherapy sessions, radiopharmaceutical administration, radiological scans, etc. The aim of this article is to reduce the error in the identification of correct patients by implementation of the Python deep learning-based real-time patient identification program. Materials and Methods The authors utilized and installed Anaconda Prompt (miniconda 3), Python (version 3.9.12), and Visual Studio Code (version 1.71.0) for the design of the patient identification program. In the field of view, the area of interest is merely face detection. The overall performance of the developed program is accomplished over three steps, namely image data collection, data transfer, and data analysis, respectively. The patient identification tool was developed using the OpenCV library for face recognition. Results This program provides real-time patient identification information, together with the other preset parameters such as disease site, with a precision of 0.92%, recall rate of 0.80%, and specificity of 0.90%. Furthermore, the accuracy of the program was found to be 0.84%. The output of the in-house developed program as "Unknown" is provided if a patient's relative or an unknown person is found in restricted region. Interpretation and Conclusions This Python-based program is beneficial for confirming the patient's identity, without manual interventions, just before therapy, administering medications, and starting other medical procedures, among other things, to prevent unintended medical and health-related complications that may arise as a result of misidentification.
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Affiliation(s)
- Shriram Rajurkar
- Department of Radiotherapy, King George’s Medical University, UP, India
| | - Teerthraj Verma
- Department of Radiotherapy, King George’s Medical University, UP, India
| | - S P Mishra
- Department of Radiation Oncology, Dr RMLIMS, Lucknow, India
| | - MLB Bhatt
- Department of Radiotherapy, King George’s Medical University, UP, India
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Ben Mustapha S, Cucchiaro S, Goreux J, Delgaudine M, Boga D, Donneau AF, Diep AN, Coucke P. Comparison between the WHO-CFICPS and the PRISMA classification of safety-related events in a radiation oncology department. J Med Imaging Radiat Oncol 2023; 67:531-538. [PMID: 37138510 DOI: 10.1111/1754-9485.13536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 04/17/2023] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Selma Ben Mustapha
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
| | - Séverine Cucchiaro
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
| | - Joelle Goreux
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
| | - Marie Delgaudine
- Department of Medical Imaging, Centre Hospitalier Chrétien, Liège, Belgium
| | - Deniz Boga
- University Hospital of Liège, Liege, Belgium
| | | | - Anh Nguyet Diep
- Biostatistics Unit, Faculty of Medicine, University of Liège, Liege, Belgium
| | - Philippe Coucke
- Department of Radiation Oncology, University Hospital of Liège, Liege, Belgium
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Zarei M, Gershan V, Holmberg O. Safety in radiation oncology (SAFRON): Learning about incident causes and safety barriers in external beam radiotherapy. Phys Med 2023; 111:102618. [PMID: 37311337 DOI: 10.1016/j.ejmp.2023.102618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE Safety in Radiation Oncology (SAFRON) is a reporting and learning system on radiotherapy and radionuclide therapy incidents and near misses. The primary aim of this paper is to examine whether any discernible patterns exist in the causes of reported incidents and safety barriers within the SAFRON system concerning external beam radiotherapy. METHODS AND MATERIALS This study focuses on external beam radiotherapy incidents, reviewing 1685 reports since the inception of SAFRON until December 2021. Reports that did not identify causes of incidents and safety barriers were excluded from the final study population. RESULTS Simple two-dimensional radiotherapy or electron beam therapy were represented by 97 reports, three-dimensional conformal radiotherapy by 39 reports, modulated arc therapy by 12 reports, intensity modulated radiation therapy by 11 reports, stereotactic radiosurgery by 4 reports, and radiotherapy with protons or other particles by 1 report, while for 92 of them, no information on treatment method had been provided. Most of the reported incidents were minor incidents and were discovered by the radiation therapist. Inadequate direction/information in staff communication was the most frequently reported cause of incident, and regular independent chart check was the most common safety barrier. CONCLUSIONS The results indicate that the majority of incidents were reported by radiation therapists, and the majority of these incidents were classified as minor. Communication problems and failure to follow standards/procedures/practices were the most frequent causes of incidents. Furthermore, regular independent chart checking was the most frequently identified safety barrier.
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Affiliation(s)
- Maryam Zarei
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria.
| | - Vesna Gershan
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria
| | - Ola Holmberg
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria
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McGurk R, Naheedy KW, Kosak T, Hobbs A, Mullins BT, Paradis KC, Kearney M, Roback D, Durney J, Adapa K, Chera BS, Marks LB, Moran JM, Mak RH, Mazur LM. Multi-Institutional Stereotactic Body Radiation Therapy Incident Learning: Evaluation of Safety Barriers Using a Human Factors Analysis and Classification System. J Patient Saf 2023; 19:e18-e24. [PMID: 35948321 PMCID: PMC9771927 DOI: 10.1097/pts.0000000000001071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES Stereotactic body radiation therapy (SBRT) can improve therapeutic ratios and patient convenience, but delivering higher doses per fraction increases the potential for patient harm. Incident learning systems (ILSs) are being increasingly adopted in radiation oncology to analyze reported events. This study used an ILS coupled with a Human Factor Analysis and Classification System (HFACS) and barriers management to investigate the origin and detection of SBRT events and to elucidate how safeguards can fail allowing errors to propagate through the treatment process. METHODS Reported SBRT events were reviewed using an in-house ILS at 4 institutions over 2014-2019. Each institution used a customized care path describing their SBRT processes, including designated safeguards to prevent error propagation. Incidents were assigned a severity score based on the American Association of Physicists in Medicine Task Group Report 275. An HFACS system analyzed failing safeguards. RESULTS One hundred sixty events were analyzed with 106 near misses (66.2%) and 54 incidents (33.8%). Fifty incidents were designated as low severity, with 4 considered medium severity. Incidents most often originated in the treatment planning stage (38.1%) and were caught during the pretreatment review and verification stage (37.5%) and treatment delivery stage (31.2%). An HFACS revealed that safeguard failures were attributed to human error (95.2%), routine violation (4.2%), and exceptional violation (0.5%) and driven by personnel factors 32.1% of the time, and operator condition also 32.1% of the time. CONCLUSIONS Improving communication and documentation, reducing time pressures, distractions, and high workload should guide proposed improvements to safeguards in radiation oncology.
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Affiliation(s)
- Ross McGurk
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | - Tara Kosak
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Amy Hobbs
- Rex Cancer Center - UNC Rex Healthcare, Raleigh, NC
| | - Brandon T Mullins
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kelly C Paradis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Meghan Kearney
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | | | - Jeffrey Durney
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Karthik Adapa
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bhishamjit S Chera
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Lawrence B Marks
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI
| | - Raymond H Mak
- Department of Radiation Oncology, Brigham and Women’s Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - Lukasz M Mazur
- Department of Radiation Oncology, The University of North Carolina at Chapel Hill, Chapel Hill, NC
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Failure modes in stereotactic radiosurgery. A narrative review. Radiography (Lond) 2022; 28:999-1009. [PMID: 35921732 DOI: 10.1016/j.radi.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 07/03/2022] [Accepted: 07/11/2022] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Stereotactic radiosurgery (SRS) refers to an advanced radiotherapy technique that requires a high level of precision and accuracy and a flawless workflow. Failures within the SRS process can lead to serious consequences due to high doses delivered per treatment. This narrative review aimed to identify the riskiest failure modes (FMs) and the stages at which they occur in the SRS process, as well as the strategies applied to mitigate the risks. It was based on the analysis of published failure mode and effects analysis (FMEA) data. KEY FINDINGS From the literature search in PubMed and Scopus, 7 articles met the eligibility criteria for inclusion in the qualitative synthesis. In total, 9 radiotherapy departments conducted FMEA in the SRS process. 4 of them were community hospitals and 5 were academic centers. Overall, 54 high-risk FMs were identified with treatment planning (FMs: 18), treatment delivery (FMs: 12), consultation and patient registration (FMs: 10) being the riskiest stages. 10 FMs were stereotactic specific, while the remaining 44 could be met in any radiotherapy technique. Failures associated with contouring, medical records review, target reirradiation, and patient positioning were mostly outlined. Risk mitigation strategies included timeouts, double-checks, checklists, training and changes in the working practice. CONCLUSION Our review demonstrated that crucial FMs can occur in all SRS stages. Although generalisations were challenging, the FMs analysis provided a significant source of information about potential high risks and continuous improvement strategies that can be applied both in the SRS and other radiotherapy processes. IMPLICATIONS FOR PRACTICE The results of this research will assist radiotherapy facilities in proactive risk management studies and will allow radiotherapy professionals to reflect on their practice and learn from others' experiences.
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Adamson L, Beldham‐Collins R, Sykes J, Thwaites D. Evaluating incident learning systems and safety culture in two radiation oncology departments. J Med Radiat Sci 2022; 69:208-217. [PMID: 34882982 PMCID: PMC9163481 DOI: 10.1002/jmrs.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/15/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC. METHODS A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs. RESULTS Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no-blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS. CONCLUSION An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.
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Affiliation(s)
- Laura Adamson
- Department of Radiation OncologyCrown Princess Mary Cancer CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyBlacktown Cancer & Haematology CentreSydneyNew South WalesAustralia
- School of Physics, Institute of Medical PhysicsUniversity of SydneySydneyNew South WalesAustralia
| | - Rachael Beldham‐Collins
- Department of Radiation OncologyCrown Princess Mary Cancer CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyBlacktown Cancer & Haematology CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyNepean Hospital Cancer Care CentreSydneyNew South WalesAustralia
| | - Jonathan Sykes
- Department of Radiation OncologyCrown Princess Mary Cancer CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyBlacktown Cancer & Haematology CentreSydneyNew South WalesAustralia
- School of Physics, Institute of Medical PhysicsUniversity of SydneySydneyNew South WalesAustralia
| | - David Thwaites
- School of Physics, Institute of Medical PhysicsUniversity of SydneySydneyNew South WalesAustralia
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Arnold A, Ward I, Gandhidasan S. Incident review in radiation oncology. J Med Imaging Radiat Oncol 2022; 66:291-298. [PMID: 35243784 DOI: 10.1111/1754-9485.13358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/10/2021] [Indexed: 11/29/2022]
Abstract
By its very nature, radiation oncology is a complex, multi-profession dynamic modality of cancer treatment. There are multiple steps with many handovers of work and many opportunities for patient safety to be compromised. Patient safety events can manifest as either actual incidents or near miss/close call events. Reporting and learning from these events is key to quality improvement and patient safety. In this paper, we aim to provide an overview of radiation oncology incident reporting and learning systems. We review the importance of the use of a standardized taxonomy and classification that is specific to radiation oncology workflow, the international systems in current use and the current reporting requirements in Australia and New Zealand. Equally important is the culture that exists alongside the incident learning system. A just culture, where support for reporting exists and there is an adaptive responsive environment to learn and improve patient safety. The incident learning and patient safety system requires constant effort to make it a success. We describe potential measures of safety culture and of relative patient safety and recommend their routine use. We offer this review to stimulate the effort towards a binational voluntary incident learning system, a key pillar for the improvement in patient safety in radiation oncology.
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Affiliation(s)
- Anthony Arnold
- Illawarra Shoalhaven Cancer and Haematology Network, Wollongong, New South Wales, Australia
| | - Iain Ward
- Canterbury Regional Cancer and Haematology Service, Christchurch Hospital, Christchurch, New Zealand
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Müller BS, Singer J, Stamm G, Pirl L, Borowski M, Hertlein T, Rerich E, Trinkl S, Wucherer M, Ammon J. Handling of Incidents in the Clinical Application of Ionizing Radiation in Diagnostic and Interventional Radiology - a Multi-center Study. ROFO-FORTSCHR RONTG 2021; 194:400-408. [PMID: 34933352 DOI: 10.1055/a-1665-6988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE According to the German legislation and regulation of radiation protection, i. e. Strahlenschutzgesetz und Strahlenschutzverordnung (StrlSchG and StrlSchV), which came into force on 31st December 2018, significant unintended or accidential exposures have to be reported to the competent authority. Furthermore, facilities have to implement measures to prevent and to recognize unintended or accidental exposures as well as to reduce their consequences. We developed a process to register incidents and tested its application in the framework of a multi-center-study. MATERIALS AND METHODS Over a period of 12 months, 16 institutions for x-ray diagnostics and interventions, documented their incidents. Documentation of the incidents was conducted using the software CIRSrad, which was developed, released for testing purposes and implemented in the frame of the study. Reporting criteria of the project were selected to be more sensitive compared to the legal criteria specifying "significant incidents". Reported incidents were evaluated after four, eight, and twelve months. Finally, all participating institutions were interviewed on their experience with the software and the correlated effort. RESULTS The rate of reported incidents varied between institutions as well as between modalities. The majority of incidents were reported in conventional x-ray imaging, followed by computed tomography and therapeutic interventions. Incidents were attributed to several different causes, amongst others to the technical setup and patient positioning (19 %) and patient movement or insufficient cooperativeness of the patient (18 %). Most incidents were below corresponding thresholds stated in StrlSchV. The workload for documenting the incidents was rated as appropriate. CONCLUSION It is possible to monitor and handle incidents complient with legal requirements with an acceptable effort. The number of reported incidents can be increased by frequent trainings on the detection and the processing workflow, on the software and legal regulation as well as by a transparent error handling within the institution. KEY POINTS · The software CIRSrad was developed to enable the present study and as prototype platform for a future radiological incident management system.. · 586 exceedances of thresholds were recorded by 16 facilities in a period of one year.. · Frequent trainings of all users increase the number of reported cases.. CITATION FORMAT · Müller BS, Singer J, Stamm G et al. Handling of Incidents in the Clinical Application of Ionizing Radiation in Diagnostic and Interventional Radiology - a Multi-center Study. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1665-6988.
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Affiliation(s)
- Birgit Sabine Müller
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Julian Singer
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Georg Stamm
- Institute for Diagnostic and Interventional Radiology, University Medical Center Gottingen, Gottingen, Germany
| | - Lukas Pirl
- Institute for Diagnostic Radiology and Nuclear medicine, Braunschweig Municipal Hospital, Braunschweig, Germany
| | - Markus Borowski
- Institute for Diagnostic Radiology and Nuclear medicine, Braunschweig Municipal Hospital, Braunschweig, Germany
| | - Thomas Hertlein
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Eugenia Rerich
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany.,Medizinphysik-Experten für sonstige Einrichtungen, Charite University Hospital Berlin, Germany
| | - Sebastian Trinkl
- External and Internal Dosimetry, Biokinetics, Federal Office for Radiation Protection Neuherberg, Germany
| | - Michael Wucherer
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
| | - Josefin Ammon
- Institute of Medical Physics, Klinikum Nurnberg, Paracelsus Medical University, Nurnberg, Germany
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Mathew F, Wang H, Montgomery L, Kildea J. Natural language processing and machine learning to assist radiation oncology incident learning. J Appl Clin Med Phys 2021; 22:172-184. [PMID: 34610206 PMCID: PMC8598135 DOI: 10.1002/acm2.13437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/02/2021] [Accepted: 09/16/2021] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To develop a Natural Language Processing (NLP) and Machine Learning (ML) pipeline that can be integrated into an Incident Learning System (ILS) to assist radiation oncology incident learning by semi-automating incident classification. Our goal was to develop ML models that can generate label recommendations, arranged according to their likelihoods, for three data elements in Canadian NSIR-RT taxonomy. METHODS Over 6000 incident reports were gathered from the Canadian national ILS as well as our local ILS database. Incident descriptions from these reports were processed using various NLP techniques. The processed data with the expert-generated labels were used to train and evaluate over 500 multi-output ML algorithms. The top three models were identified and tuned for each of three different taxonomy data elements, namely: (1) process step where the incident occurred, (2) problem type of the incident and (3) the contributing factors of the incident. The best-performing model after tuning was identified for each data element and tested on unseen data. RESULTS The MultiOutputRegressor extended Linear SVR models performed best on the three data elements. On testing, our models ranked the most appropriate label 1.48 ± 0.03, 1.73 ± 0.05 and 2.66 ± 0.08 for process-step, problem-type and contributing factors respectively. CONCLUSIONS We developed NLP-ML models that can perform incident classification. These models will be integrated into our ILS to generate a drop-down menu. This semi-automated feature has the potential to improve the usability, accuracy and efficiency of our radiation oncology ILS.
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Affiliation(s)
- Felix Mathew
- Medical Physics UnitMcGill UniversityMontrealQuebecH4A3J1Canada
| | - Hui Wang
- UnaffiliatedMontrealQuebecCanada
| | | | - John Kildea
- Medical Physics UnitMcGill UniversityMontrealQuebecH4A3J1Canada
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Xu H, Zhang B, Guerrero M, Lee SW, Lamichhane N, Chen S, Yi B. Toward automation of initial chart check for photon/electron EBRT: the clinical implementation of new AAPM task group reports and automation techniques. J Appl Clin Med Phys 2021; 22:234-245. [PMID: 33705604 PMCID: PMC7984492 DOI: 10.1002/acm2.13200] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 12/01/2020] [Accepted: 01/21/2021] [Indexed: 11/22/2022] Open
Abstract
Purpose The recently published AAPM TG‐275 and the public review version of TG‐315 list new recommendations for comprehensive and minimum physics initial chart checks, respectively. This article addresses the potential development and benefit of initial chart check automation when these recommendations are implemented for clinical photon/electron EBRT. Methods Eight board‐certified physicists with 2–20 years of clinical experience performed initial chart checks using checklists from TG‐275 and TG‐315. Manual check times were estimated for three types of plans (IMRT/VMAT, 3D, and 2D) and for prostate, whole pelvis, lung, breast, head and neck, and brain cancers. An expert development team of three physicists re‐evaluated the automation feasibility of TG‐275 checklist based on their experience of developing and implementing the in‐house and the commercial automation tools in our institution. Three levels of initial chart check automation were simulated: (1) Auto_UMMS_tool (which consists of in‐house program and commercially available software); (2) Auto_TG275 (with full and partial automation as indicated in TG‐275); and (3) Auto_UMMS_exp (with full and partial automation as determined by our experts’ re‐evaluation). Results With no automation of initial chart checks, the ranges of manual check times were 29–56 min (full TG‐315 list) and 102–163 min (full TG‐275 list), which varied significantly with physicists but varied little at different tumor sites. The 69 of 71 checks which were considered as “not fully automated” in TG‐275 were re‐evaluated with more automation feasibility. Compared to no automation, the higher levels of automation yielded a great reduction in both manual check times (by 44%–98%) and potentially residual detectable errors (by 15–85%). Conclusion The initial chart check automation greatly improves the practicality and efficiency of implementing the new TG recommendations. Revisiting the TG reports with new technology/practice updates may help develop and utilize more automation clinically.
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Affiliation(s)
- Huijun Xu
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Baoshe Zhang
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Sung-Woo Lee
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Shifeng Chen
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Byongyong Yi
- University of Maryland School of Medicine, Baltimore, MD, USA
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Critical success factors for implementation of an incident learning system in radiation oncology department. Rep Pract Oncol Radiother 2020; 25:994-1000. [PMID: 33132764 DOI: 10.1016/j.rpor.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 07/30/2020] [Accepted: 09/10/2020] [Indexed: 11/24/2022] Open
Abstract
Aim The aim of this study was to analyze critical success factors (CSFs) for implementation of an incident learning system (ILS) in a radiation oncology department (ROD) and evaluate the perception of the staff members along this process. Background Implementing an ILS is a way to leverage learning from incidents and is a tool for improving patient safety, consisting of a cycle of reporting and analyzing events as well as taking preventive actions. ILS implementation is challenging, requiring specific resources and cultural changes. Materials and methods An ILS was designed and implemented based on the CSF identified in the literature review. Before starting the ILS implementation, a structured survey was applied to assess dimensions of patient safety culture. After the period of implementation (7 months), the survey was applied again and compared with the initial assessment, and interviews were performed with staff members to evaluate the overall satisfaction with ILS and CSFs. Results Statistically significant improvements were observed in 5 dimensions (12 totals) of the safety culture survey, considering time points before and after the ILS implementation. According to interviewees, "Facilitating committee", "Efficient data collection", "Focus on improvement", "Just culture" and "Feedback to users" were the most relevant CSFs. Conclusions The ILS designed and implemented at ROD was perceived as an important tool to support quality and safety initiatives, promoting the improvement in safety culture. The ILS implementation critical success factors were identified and have shown good agreement between the results of the literature and the users' practical perception.
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The role of the radiation oncologist in quality and patient safety: A proposal of indicators and metrics. Crit Rev Oncol Hematol 2020; 154:103045. [DOI: 10.1016/j.critrevonc.2020.103045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 06/29/2020] [Indexed: 11/21/2022] Open
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Mir R, Kelly SM, Xiao Y, Moore A, Clark CH, Clementel E, Corning C, Ebert M, Hoskin P, Hurkmans CW, Ishikura S, Kristensen I, Kry SF, Lehmann J, Michalski JM, Monti AF, Nakamura M, Thompson K, Yang H, Zubizarreta E, Andratschke N, Miles E. Organ at risk delineation for radiation therapy clinical trials: Global Harmonization Group consensus guidelines. Radiother Oncol 2020; 150:30-39. [DOI: 10.1016/j.radonc.2020.05.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/12/2020] [Accepted: 05/24/2020] [Indexed: 12/25/2022]
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Woulfe P, Sullivan FJ, Kam W, O’Keeffe S. Optical fiber dosimeter for real-time in-vivo dose monitoring during LDR brachytherapy. BIOMEDICAL OPTICS EXPRESS 2020; 11:4027-4036. [PMID: 33014583 PMCID: PMC7510901 DOI: 10.1364/boe.385610] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 05/28/2023]
Abstract
An optical fiber sensor for monitoring low dose radiation is presented. The sensor, based on radiation sensitive scintillation material, terbium doped gadolinium oxysulphide (Gd2O2S:Tb), is embedded in a cavity of 700µm diameter within a 1mm plastic optical fiber. The sensor is compared with the treatment planning system for repeatability, angular dependency, distance and accumulated radiation activity. The sensor demonstrates a high sensitivity of 152 photon counts/Gy with a temporal resolution of 0.1 seconds, with the largest repeatability error of 4.1%, to 0.361mCi of Iodine-125 the radioactive source most commonly used in LDR brachytherapy for treating prostate cancer.
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Affiliation(s)
- P. Woulfe
- Optical Fiber Sensors Research Centre, University of Limerick, Ireland
- Dept. of Radiotherapy Physics, Galway Clinic, Ireland
| | - F. J. Sullivan
- Prostate Cancer Institute, National University of Ireland Galway, Ireland
- Department of Radiotherapy, Galway Clinic, Ireland
| | - W. Kam
- Optical Fiber Sensors Research Centre, University of Limerick, Ireland
| | - S. O’Keeffe
- Optical Fiber Sensors Research Centre, University of Limerick, Ireland
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Beltran Vilagrasa M, Varó Curbelo A, Fa Asensio X, García Relancio D, Giralt López de Sagredo J. [Safety in radiationtherapy. Results after 9 years implementation of incidents reporting system]. J Healthc Qual Res 2020; 35:173-181. [PMID: 32467079 DOI: 10.1016/j.jhqr.2020.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 06/11/2023]
Abstract
INTRODUCTION Radiation therapy (RT) is a complex process that employs high-dose radiation for therapeutic purposes. Incident reporting and analysis, in addition to being a legal requirement in RT, provides information that helps to improve patient safety. This paper describes our experiences over a 9 year period in which a local incident reporting and learning system (SNAI) specific to RT was employed. MATERIALS AND METHODS The center has 4 lineal accelerators that treat a total of 1900 patients annually. The first action taken with a view to improving patient safety was the implementation of a multidisciplinary RT safety group (GSRT), who decided to employing a methodology based on incident reporting. For this purpose, a local SNAI was implemented, adapting the ROSEIS incident reporting system used and consolidated by the European Society of Radiation Oncology Therapy (ESTRO). All incidents in which patients received an incorrect RT session were considered adverse events (AE) and were thus analyzed. Finally, the opinion of the professionals involved in relation to the SNAI and the functioning of the safety group was evaluated by means of a survey. RESULTS From June 2009 to October 2018, 1708 incidents were recorded, with an increasing incidence observed over time. Approximately 2.5% of the incidents reported were AE. The remainders were events that did not affect the patient. As many as 55% of incidents were detected in the treatment administration phase. Radiotherapy technicians were the professionals who reported more incidents. The majority of recorded cases originated from procedural shortcomings relating to communication or work protocols. Implemented remedial actions were aimed at reducing the frequency of AE and facilitating its early detection. Actions employed were essentially: drafting and revision of protocols and circuits, implementation of checklists, and training actions. Of the workers surveyed, 85% positively valued the incorporation of the SNAI and the existence of a safety group. However, 15% of the professionals considered that the methodology used in the analysis of incidents was not totally objective i.e punitive in nature. CONCLUSIONS The safety of the patient receiving RT has been approached from a methodology based on a local SNAI. The analysis of reported incidents has promoted various actions aimed at improving the safety of patients receiving RT. The methodology used has been well received by the workers and has helped to introduce a culture of patient safety for the majority of professionals involved. Furthermore, the local SNAI facilitates compliance with European regulations regarding the obligation to record incidents in RT.
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Affiliation(s)
- M Beltran Vilagrasa
- Servicio de Física y Protección Radiológica, Hospital Universitario Vall d'Hebron, Barcelona, España.
| | - A Varó Curbelo
- Servicio de Física y Protección Radiológica, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - X Fa Asensio
- Servicio de Física y Protección Radiológica, Hospital Universitario Vall d'Hebron, Barcelona, España
| | - D García Relancio
- Servicio de Oncología Radioterápica, Hospital Universitario Vall d'Hebron, Barcelona, España
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Paradis KC, Naheedy KW, Matuszak MM, Kashani R, Burger P, Moran JM. The Fusion of Incident Learning and Failure Mode and Effects Analysis for Data-Driven Patient Safety Improvements. Pract Radiat Oncol 2020; 11:e106-e113. [PMID: 32201319 DOI: 10.1016/j.prro.2020.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 11/19/2022]
Abstract
PURPOSE Incident learning is a critical part of the quality improvement process for all radiation therapy clinics. Failure mode and effects analysis has also been adopted as a hazard analysis method within the field of radiation oncology based on the recommendations of American Association of Physicists in Medicine Task Group 100. In this work, we demonstrate a fusion of these techniques that is efficient and transferrable to all types of clinics and that allows data-driven targeting of the highest risk error types. METHODS AND MATERIALS Four clinical physicists recorded safety events detected during physics treatment plan quality assurance over a 27-month period. Events were sorted into the broad categories of either a documentation or plan construction error. Events were further stratified into subcategories until sufficiently discriminated against for analysis. Event risks were quantified using reduced-resolution TG-100 severity scores combined with observed occurrence rates. The highest risk categories were examined for intervention strategies. RESULTS A total of 871 events were identified over the study period. Of these, 652 (74.9%) were classified as low severity, 178 (20.4%) as medium severity, and 41 (4.7%) as high severity. Four of the top 5 ranked categories could be targeted by a preplanning chart rounds. Several of the categories could be targeted by additional automation in the planning and QA processes. CONCLUSIONS The retrospective classification and risk analysis of safety events allows clinics to design targeted workflow and quality assurance changes aimed at reducing the occurrence of high-risk events. The method presented here leverages incident learning efforts that many clinics are already performing, allows the severity of events to be efficiently assigned, and generates actionable results without requiring a complete failure mode and effects analysis.
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Affiliation(s)
- Kelly C Paradis
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan.
| | - Katherine Woch Naheedy
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan
| | - Martha M Matuszak
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan
| | - Rojano Kashani
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan
| | - Pamela Burger
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jean M Moran
- Department of Radiation Oncology, University of Michigan Health System, Ann Arbor, Michigan
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Shen J, Wang X, Deng D, Gong J, Tan K, Zhao H, Bao Z, Xiao J, Liu A, Zhou Y, Liu H, Xie C. Evaluation and improvement the safety of total marrow irradiation with helical tomotherapy using repeat failure mode and effects analysis. Radiat Oncol 2019; 14:238. [PMID: 31882010 PMCID: PMC6935229 DOI: 10.1186/s13014-019-1433-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/29/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND & PURPOSE Helical tomotherapy has been applied to total marrow irradiation (HT-TMI). Our objective was to apply failure mode and effects analysis (FMEA) two times separated by 1 year to evaluate and improve the safety of HT-TMI. MATERIALS AND METHODS A multidisciplinary team was created. FMEA consists of 4 main steps: (1) Creation of a process map; (2) Identification of all potential failure mode (FM) in the process; (3) Evaluation of the occurrence (O), detectability (D) and severity of impact (S) of each FM according to a scoring criteria (1-10), with the subsequent calculation of the risk priority number (RPN=O*D*S) and (4) Identification of the feasible and effective quality control (QC) methods for the highest risks. A second FMEA was performed for the high-risk FMs based on the same risk analysis team in 1 year later. RESULTS A total of 39 subprocesses and 122 FMs were derived. First time RPN ranged from 3 to 264.3. Twenty-five FMs were defined as being high-risk, with the top 5 FMs (first RPN/ second RPN): (1) treatment couch movement failure (264.3/102.8); (2) section plan dose junction error in delivery (236.7/110.4); (3) setup check by megavoltage computed tomography (MVCT) failure (216.8/94.6); (4) patient immobilization error (212.5/90.2) and (5) treatment interruption (204.8/134.2). A total of 20 staff members participated in the study. The second RPN value of the top 5 high-risk FMs were all decreased. CONCLUSION QC interventions were implemented based on the FMEA results. HT-TMI specific treatment couch tests; the arms immobilization methods and strategy of section plan dose junction in delivery were proved to be effective in the improvement of the safety.
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Affiliation(s)
- Jiuling Shen
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Xiaoyong Wang
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Di Deng
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Jian Gong
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Kang Tan
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Hongli Zhao
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Zhirong Bao
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Jinping Xiao
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - An Liu
- Divisions of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Yunfeng Zhou
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China.,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China
| | - Hui Liu
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China. .,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China.
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, Hubei, 430070, People's Republic of China. .,Hubei Radiotherapy Quality Control Center, Wuhan University, Wuhan, Hubei, China.
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Willoughby TR, Meeks SL, Kelly P, Dvorak T, Muller K, Dana TM, Bova F. Development of a Virtual Radiation Oncology Clinic for training and simulation of errors in the radiation oncology workflow. Pract Radiat Oncol 2018; 8:239-244. [DOI: 10.1016/j.prro.2018.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 12/29/2017] [Accepted: 01/07/2018] [Indexed: 11/17/2022]
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Greenham S, Manley S, Turnbull K, Hoffmann M, Fonseca A, Westhuyzen J, Last A, Aherne NJ, Shakespeare TP. Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres. Rep Pract Oncol Radiother 2018; 23:220-227. [PMID: 29760597 PMCID: PMC5948319 DOI: 10.1016/j.rpor.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/05/2018] [Accepted: 04/08/2018] [Indexed: 10/16/2022] Open
Abstract
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.
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Affiliation(s)
- Stuart Greenham
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Stephen Manley
- Department of Radiation Oncology, Northern New South Wales Cancer Institute, Lismore, New South Wales, Australia
| | - Kirsty Turnbull
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Matthew Hoffmann
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Amara Fonseca
- Department of Radiation Oncology, Northern New South Wales Cancer Institute, Lismore, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Andrew Last
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Noel J. Aherne
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
| | - Thomas P. Shakespeare
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
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Montgomery L, Fava P, Freeman CR, Hijal T, Maietta C, Parker W, Kildea J. Development and implementation of a radiation therapy incident learning system compatible with local workflow and a national taxonomy. J Appl Clin Med Phys 2018; 19:259-270. [PMID: 29165915 PMCID: PMC5767999 DOI: 10.1002/acm2.12218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 09/05/2017] [Accepted: 10/06/2017] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Collaborative incident learning initiatives in radiation therapy promise to improve and standardize the quality of care provided by participating institutions. However, the software interfaces provided with such initiatives must accommodate all participants and thus are not optimized for the workflows of individual radiation therapy centers. This article describes the development and implementation of a radiation therapy incident learning system that is optimized for a clinical workflow and uses the taxonomy of the Canadian National System for Incident Reporting - Radiation Treatment (NSIR-RT). METHODS The described incident learning system is a novel version of an open-source software called the Safety and Incident Learning System (SaILS). A needs assessment was conducted prior to development to ensure SaILS (a) was intuitive and efficient (b) met changing staff needs and (c) accommodated revisions to NSIR-RT. The core functionality of SaILS includes incident reporting, investigations, tracking, and data visualization. Postlaunch modifications of SaILS were informed by discussion and a survey of radiation therapy staff. RESULTS There were 240 incidents detected and reported using SaILS in 2016 and the number of incidents per month tended to increase throughout the year. An increase in incident reporting occurred after switching to fully online incident reporting from an initial hybrid paper-electronic system. Incident templating functionality and a connection with our center's oncology information system were incorporated into the investigation interface to minimize repetitive data entry. A taskable actions feature was also incorporated to document outcomes of incident reports and has since been utilized for 36% of reported incidents. CONCLUSIONS Use of SaILS and the NSIR-RT taxonomy has improved the structure of, and staff engagement with, incident learning in our center. Software and workflow modifications informed by staff feedback improved the utility of SaILS and yielded an efficient and transparent solution to categorize incidents with the NSIR-RT taxonomy.
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Affiliation(s)
- Logan Montgomery
- Medical Physics UnitDepartment of PhysicsMcGill UniversityMontréalCanada
| | - Palma Fava
- Division of Radiation OncologyDepartment of OncologyMcGill UniversityMontréalCanada
| | - Carolyn R. Freeman
- Division of Radiation OncologyDepartment of OncologyMcGill UniversityMontréalCanada
| | - Tarek Hijal
- Division of Radiation OncologyDepartment of OncologyMcGill UniversityMontréalCanada
| | - Ciro Maietta
- Division of Radiation OncologyDepartment of OncologyMcGill UniversityMontréalCanada
| | - William Parker
- Medical Physics UnitDepartment of OncologyMcGill UniversityMontréalCanada
| | - John Kildea
- Medical Physics UnitDepartment of OncologyMcGill UniversityMontréalCanada
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American Association of Physicists in Medicine Task Group 263: Standardizing Nomenclatures in Radiation Oncology. Int J Radiat Oncol Biol Phys 2017; 100:1057-1066. [PMID: 29485047 PMCID: PMC7437157 DOI: 10.1016/j.ijrobp.2017.12.013] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/03/2017] [Accepted: 12/06/2017] [Indexed: 11/24/2022]
Abstract
A substantial barrier to the single- and multi-institutional aggregation of data to supporting clinical trials, practice quality improvement efforts, and development of big data analytics resource systems is the lack of standardized nomenclatures for expressing dosimetric data. To address this issue, the American Association of Physicists in Medicine (AAPM) Task Group 263 was charged with providing nomenclature guidelines and values in radiation oncology for use in clinical trials, data-pooling initiatives, population-based studies, and routine clinical care by standardizing: (1) structure names across image processing and treatment planning system platforms; (2) nomenclature for dosimetric data (eg, dose-volume histogram [DVH]-based metrics); (3) templates for clinical trial groups and users of an initial subset of software platforms to facilitate adoption of the standards; (4) formalism for nomenclature schema, which can accommodate the addition of other structures defined in the future. A multisociety, multidisciplinary, multinational group of 57 members representing stake holders ranging from large academic centers to community clinics and vendors was assembled, including physicists, physicians, dosimetrists, and vendors. The stakeholder groups represented in the membership included the AAPM, American Society for Radiation Oncology (ASTRO), NRG Oncology, European Society for Radiation Oncology (ESTRO), Radiation Therapy Oncology Group (RTOG), Children's Oncology Group (COG), Integrating Healthcare Enterprise in Radiation Oncology (IHE-RO), and Digital Imaging and Communications in Medicine working group (DICOM WG); A nomenclature system for target and organ at risk volumes and DVH nomenclature was developed and piloted to demonstrate viability across a range of clinics and within the framework of clinical trials. The final report was approved by AAPM in October 2017. The approval process included review by 8 AAPM committees, with additional review by ASTRO, European Society for Radiation Oncology (ESTRO), and American Association of Medical Dosimetrists (AAMD). This Executive Summary of the report highlights the key recommendations for clinical practice, research, and trials.
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Ford EC, Nyflot M, Spraker MB, Kane G, Hendrickson KRG. A patient safety education program in a medical physics residency. J Appl Clin Med Phys 2017; 18:268-274. [PMID: 28895282 PMCID: PMC5689904 DOI: 10.1002/acm2.12166] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 03/29/2017] [Accepted: 05/23/2017] [Indexed: 11/11/2022] Open
Abstract
Education in patient safety and quality of care is a requirement for radiation oncology residency programs according to accrediting agencies. However, recent surveys indicate that most programs lack a formal program to support this learning. The aim of this report was to address this gap and share experiences with a structured educational program on quality and safety designed specifically for medical physics therapy residencies. Five key topic areas were identified, drawn from published recommendations on safety and quality. A didactic component was developed, which includes an extensive reading list supported by a series of lectures. This was coupled with practice-based learning which includes one project, for example, failure modes and effect analysis exercise, and also continued participation in the departmental incident learning system including a root-cause analysis exercise. Performance was evaluated through quizzes, presentations, and reports. Over the period of 2014-2016, five medical physics residents successfully completed the program. Evaluations indicated that the residents had a positive experience. In addition to educating physics residents this program may be adapted for medical physics graduate programs or certificate programs, radiation oncology residencies, or as a self-directed educational project for practicing physicists. Future directions might include a system that coordinates between medical training centers such as a resident exchange program.
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Affiliation(s)
- Eric C. Ford
- Department of Radiation OncologyUniversity of WashingtonSeattleWA98195USA
| | - Matthew Nyflot
- Department of Radiation OncologyUniversity of WashingtonSeattleWA98195USA
| | - Matthew B. Spraker
- Department of Radiation OncologyUniversity of WashingtonSeattleWA98195USA
| | - Gabrielle Kane
- Department of Radiation OncologyUniversity of WashingtonSeattleWA98195USA
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Dowling K, Barrett S, Mullaney L, Poole C. A nationwide investigation of radiation therapy event reporting-and-learning systems: Can standards be improved? Radiography (Lond) 2017; 23:279-286. [PMID: 28965889 DOI: 10.1016/j.radi.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 04/05/2017] [Accepted: 06/25/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Variation exists between event reporting-and-learning systems utilised in radiation therapy. Due to the impact of errors associated with this field of medicine, evidence-based and rigorous systems are imperative. The implementation of such systems facilitates the reactive enhancement of patient safety following an event. The purpose of this study was to evaluate Irish event reporting-and-learning procedures against the current literature using a developed evidence-based process map, and to propose recommendations as to how the national standard could be improved. METHODS Radiation Therapy Service Managers of all Irish radiation therapy institutions (n = 12) were invited to participate in an anonymous online questionnaire. Included in the questionnaire was a reporting-and-learning process map developed from evidence-based literature, which was used to assess the institution's practice through the use of vignettes. Frequency analysis of closed-ended questions and thematic analysis of open-ended questions was performed to assess the data. RESULTS A 91.7% response rate was achieved. The following areas were found to have the most variation with the evidence-based process map: event classification, external reporting, and dissemination of lessons-learned to a wider audience. Recommendations to standardise practice were made. CONCLUSION Opportunities for improvement exist within event reporting-and-learning systems of Irish radiation therapy institutions and recommendations have been made on these. These findings can provide learning for other countries with similar reporting systems.
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Affiliation(s)
- K Dowling
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland
| | - S Barrett
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland.
| | - L Mullaney
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland
| | - C Poole
- Applied Radiation Therapy Trinity, Discipline of Radiation Therapy, School of Medicine, Trinity College Dublin, Ireland
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Pawlicki T, Coffey M, Milosevic M. Incident Learning Systems for Radiation Oncology: Development and Value at the Local, National and International Level. Clin Oncol (R Coll Radiol) 2017; 29:562-567. [DOI: 10.1016/j.clon.2017.07.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
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Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy. Pract Radiat Oncol 2017; 7:346-353. [DOI: 10.1016/j.prro.2017.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/08/2017] [Accepted: 05/11/2017] [Indexed: 11/21/2022]
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Brachytherapy patient safety events in an academic radiation medicine program. Brachytherapy 2017; 17:16-23. [PMID: 28757402 DOI: 10.1016/j.brachy.2017.06.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 04/26/2017] [Accepted: 06/22/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE To describe the incidence and type of brachytherapy patient safety events over 10 years in an academic brachytherapy program. METHODS AND MATERIALS Brachytherapy patient safety events reported between January 2007 and August 2016 were retrieved from the incident reporting system and reclassified using the recently developed National System for Incident Reporting in Radiation Treatment taxonomy. A multi-incident analysis was conducted to identify common themes and key learning points. RESULTS During the study period, 3095 patients received 4967 brachytherapy fractions. An additional 179 patients had MR-guided prostate biopsies without treatment as part of an interventional research program. A total of 94 brachytherapy- or biopsy-related safety events (incidents, near misses, or programmatic hazards) were identified, corresponding to a rate of 2.8% of brachytherapy patients, 1.7% of brachytherapy fractions, and 3.4% of patients undergoing MR-guided prostate biopsy. Fifty-one (54%) events were classified as actual incidents, 29 (31%) as near misses, and 14 (15%) as programmatic hazards. Two events were associated with moderate acute medical harm or dosimetric severity, and two were associated with high dosimetric severity. Multi-incident analysis identified five high-risk activities or clinical scenarios as follows: (1) uncommon, low-volume or newly implemented brachytherapy procedures, (2) real-time MR-guided brachytherapy or biopsy procedures, (3) use of in-house devices or software, (4) manual data entry, and (5) patient scheduling and handoffs. CONCLUSIONS Brachytherapy is a safe treatment and associated with a low rate of patient safety events. Effective incident management is a key element of continuous quality improvement and patient safety in brachytherapy.
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Giardina M, Cantone MC, Tomarchio E, Veronese I. A Review of Healthcare Failure Mode and Effects Analysis (HFMEA) in Radiotherapy. HEALTH PHYSICS 2016; 111:317-326. [PMID: 27575344 DOI: 10.1097/hp.0000000000000536] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
This paper presents a review of risk analyses in radiotherapy (RT) processes carried out by using Healthcare Failure Mode Effect Analysis (HFMEA) methodology, a qualitative method that proactively identifies risks to patients and corrects medical errors before they occur. This literature review was performed to provide an overview of how to approach the development of HFMEA applications in modern RT procedures, comparing recently published research conducted to support proactive programs to identify risks. On the basis of the reviewed literature, the paper suggests HFMEA shortcomings that need to be addressed.
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Affiliation(s)
- M Giardina
- *Department of Energy, Information Engineering and Mathematical Models (DEIM), University of Palermo, Viale delle Scienze, Edificio 6, 90128 Palermo, Italy; †Università degli Studi di Milano, Scienze Biomediche, Chirurgiche e Odontoiatriche, and INFN, Sezione di Milano, Via Pascal 36, 20133 Milano, Italy; ‡Università degli Studi di Milano, Dipartimento di Fisica, and INFN, Sezione di Milano, Via Celoria 16, 20133, Milano, Italy
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Gopan O, Zeng J, Novak A, Nyflot M, Ford E. The effectiveness of pretreatment physics plan review for detecting errors in radiation therapy. Med Phys 2016; 43:5181. [DOI: 10.1118/1.4961010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF, Yorke ED. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Med Phys 2016; 43:4209. [PMID: 27370140 PMCID: PMC4985013 DOI: 10.1118/1.4947547] [Citation(s) in RCA: 303] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 03/13/2016] [Accepted: 03/14/2016] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- M Saiful Huq
- Department of Radiation Oncology, University of Pittsburgh Cancer Institute and UPMC CancerCenter, Pittsburgh, Pennsylvania 15232
| | - Benedick A Fraass
- Department of Radiation Oncology, Cedars-Sinai Medical Center, Los Angeles, California 90048
| | - Peter B Dunscombe
- Department of Oncology, University of Calgary, Calgary T2N 1N4, Canada
| | | | - Geoffrey S Ibbott
- Department of Radiation Physics, UT MD Anderson Cancer Center, Houston, Texas 77030
| | - Arno J Mundt
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, California 92093-0843
| | - Sasa Mutic
- Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri 63110
| | - Jatinder R Palta
- Department of Radiation Oncology, Virginia Commonwealth University, P.O. Box 980058, Richmond, Virginia 23298
| | - Frank Rath
- Department of Engineering Professional Development, University of Wisconsin, Madison, Wisconsin 53706
| | - Bruce R Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin 53705-2275
| | - Jeffrey F Williamson
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia 23298-0058
| | - Ellen D Yorke
- Department of Medical Physics, Memorial Sloan-Kettering Center, New York, New York 10065
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Zeng J, Nyflot MJ, Jordan LE, Sponseller PA, Novak A, Carlson J, Ermoian RP, Kane GM, Ford EC. Best practices for safety improvement through high-volume institutional incident learning: lessons learned from 2 years. ACTA ACUST UNITED AC 2016. [DOI: 10.1007/s13566-016-0250-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Novak A, Nyflot MJ, Ermoian RP, Jordan LE, Sponseller PA, Kane GM, Ford EC, Zeng J. Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system. Med Phys 2016; 43:2053-2062. [DOI: 10.1118/1.4944739] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Milosevic M, Angers C, Liszewski B, Drodge CS, Marchand EL, Bissonnette JP, Brown E, Dunscombe P, Hunt J, Jiang H, Louie K, Mitera G, Moran K, Panzarella T, Parliament M, Ross S, Brundage M. The Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT) Taxonomy. Pract Radiat Oncol 2016; 6:334-341. [PMID: 27068779 DOI: 10.1016/j.prro.2016.01.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/19/2016] [Accepted: 01/26/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Incident investigation, reporting, and learning are core elements of quality improvement in radiation treatment. This report describes the development of a Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT), focusing especially on the taxonomy. METHODS AND MATERIALS The NSIR-RT was developed to provide a framework in Canada for reporting and analyzing radiation treatment incidents. A key objective was to assure compatibility with other international reporting systems to facilitate future information exchange. The Canadian community was engaged at every step of the development process through Delphi consensus building and inter-user agreement testing to promote awareness of the system and motivate broad-based utilization across the country. RESULTS The final taxonomy was comprised of 6 data groups (impact, discovery, patient, details, treatment delivery, and investigation) and 33 data categories with predefined menu options. There was a high level agreement within the Canadian community about the final suite of data categories, and broad alignment of these categories with the World Health Organization and other American and European radiation treatment incident classifications. CONCLUSIONS The Canadian NSIR-RT taxonomy will be implemented as an online, web-based reporting and analysis system. It is expected that the taxonomy will evolve and mature over time to meet the changing needs of the Canadian radiation treatment community and support radiation treatment incident learning on a global scale.
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Affiliation(s)
- Michael Milosevic
- University Health Network and Princess Margaret Cancer Center, Toronto, Canada; University of Toronto, Toronto, Canada.
| | | | - Brian Liszewski
- Odette Cancer Center and Sunnybrook Hospital, Toronto, Canada
| | | | | | | | - Erika Brown
- Canadian Partnership for Quality Radiotherapy (CPQR), Red Deer, Canada
| | | | - Jordan Hunt
- Canadian Institute for Health Information, Ottawa, Canada
| | - Haiyan Jiang
- University Health Network and Princess Margaret Cancer Center, Toronto, Canada
| | - Krista Louie
- Canadian Institute for Health Information, Ottawa, Canada
| | - Gunita Mitera
- Canadian Partnership Against Cancer, Toronto, Canada
| | | | - Tony Panzarella
- University Health Network and Princess Margaret Cancer Center, Toronto, Canada
| | | | - Spencer Ross
- Canadian Institute for Health Information, Ottawa, Canada
| | - Michael Brundage
- Cancer Center of Southeastern Ontario and Queen's University, Kingston, Canada
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Denton TR, Shields LBE, Hahl M, Maudlin C, Bassett M, Spalding AC. Guidelines for treatment naming in radiation oncology. J Appl Clin Med Phys 2015; 17:123-138. [PMID: 27074449 PMCID: PMC5874902 DOI: 10.1120/jacmp.v17i2.5953] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/08/2015] [Accepted: 11/06/2015] [Indexed: 11/23/2022] Open
Abstract
Safety concerns may arise from a lack of standardization and ambiguity during the treatment planning and delivery process in radiation therapy. A standardized target and organ-at-risk naming convention in radiation therapy was developed by a task force comprised of several Radiation Oncology Societies. We present a nested-survey approach in a community setting to determine the methodology for radiation oncology departments to standardize their practice. Our Institution's continuous quality improvement (CQI) committee recognized that, due to growth from one to three centers, significant variability existed within plan parameters specific to patients' treatment. A multidiscipline, multiclinical site consortium was established to create a guideline for standard naming. Input was gathered using anonymous, electronic surveys from physicians, physicists, dosimetrists, chief therapists, and nurse managers. Surveys consisted of several primary areas of interest: anatomical sites, course naming, treatment plan naming, and treatment field naming. Additional concepts included capitalization, specification of laterality, course naming in the event of multiple sites being treated within the same course of treatment, primary versus boost planning, the use of bolus, revisions for plans, image-guidance field naming, forbidden characters, and standard units for commonly used physical quantities in radiation oncology practice. Guidelines for standard treatment naming were developed that could be readily adopted. This multidisciplinary study provides a clear, straightforward, and easily implemented protocol for the radiotherapy treatment process. Standard nomenclature facilitates the safe means of communication between team members in radiation oncology. The guidelines presented in this work serve as a model for radiation oncology clinics to standardize their practices.
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Affiliation(s)
- Travis R Denton
- The Norton Cancer Institute Radiation Center; Associates in Medical Physics.
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Nyflot MJ, Zeng J, Kusano AS, Novak A, Mullen TD, Gao W, Jordan L, Sponseller PA, Carlson JC, Kane G, Ford EC. Metrics of success: Measuring impact of a departmental near-miss incident learning system. Pract Radiat Oncol 2015; 5:e409-e416. [DOI: 10.1016/j.prro.2015.05.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Revised: 04/16/2015] [Accepted: 05/27/2015] [Indexed: 11/27/2022]
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Gabriel PE, Volz E, Bergendahl HW, Burke SV, Solberg TD, Maity A, Hahn SM. Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department. Jt Comm J Qual Patient Saf 2015; 41:160-8. [PMID: 25977200 DOI: 10.1016/s1553-7250(15)41021-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Incident learning programs have been recognized as cornerstones of safety and quality assurance in so-called high reliability organizations in industries such as aviation and nuclear power. High reliability organizations are distinguished by their drive to continuously identify and proactively address a broad spectrum of latent safety issues. Many radiation oncology institutions have reported on their experience in tracking and analyzing adverse events and near misses but few have incorporated the principles of high reliability into their programs. Most programs have focused on the reporting and retrospective analysis of a relatively small number of significant adverse events and near misses. To advance a large, multisite radiation oncology department toward high reliability, a comprehensive, cost-effective, electronic condition reporting program was launched to enable the identification of a broad spectrum of latent system failures, which would then be addressed through a continuous quality improvement process. METHODS A comprehensive program, including policies, work flows, and information system, was designed and implemented, with use of a low reporting threshold to focus on precursors to adverse events. RESULTS In a 46-month period from March 2011 through December 2014, a total of 8,504 conditions (average, 185 per month, 1 per patient treated, 3.9 per 100 fractions [individual treatments]) were reported. Some 77.9% of clinical staff members reported at least 1 condition. Ninety-eight percent of conditions were classified in the lowest two of four severity levels, providing the opportunity to address conditions before they contribute to adverse events. CONCLUSIONS Results after approximately four years show excellent employee engagement, a sustained rate of reporting, and a focus on low-level issues leading to proactive quality improvement interventions.
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Affiliation(s)
- Peter E Gabriel
- Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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Kusano AS, Nyflot MJ, Zeng J, Sponseller PA, Ermoian R, Jordan L, Carlson J, Novak A, Kane G, Ford EC. Measurable improvement in patient safety culture: A departmental experience with incident learning. Pract Radiat Oncol 2015; 5:e229-e237. [DOI: 10.1016/j.prro.2014.07.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 07/04/2014] [Accepted: 07/07/2014] [Indexed: 11/30/2022]
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Coeytaux K, Bey E, Christensen D, Glassman ES, Murdock B, Doucet C. Reported radiation overexposure accidents worldwide, 1980-2013: a systematic review. PLoS One 2015; 10:e0118709. [PMID: 25789482 PMCID: PMC4366065 DOI: 10.1371/journal.pone.0118709] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/06/2015] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Radiation overexposure accidents are rare but can have severe long-term health consequences. Although underreporting can be an issue, some extensive literature reviews of reported radiation overexposures have been performed and constitute a sound basis for conclusions on general trends. Building further on this work, we performed a systematic review that completes previous reviews and provides new information on characteristics and trends of reported radiation accidents. METHODS We searched publications and reports from MEDLINE, EMBASE, the International Atomic Energy Agency, the International Radiation Protection Association, the United Nations Scientific Committee on the Effects of Atomic Radiation, the United States Nuclear Regulatory Commission, and the Radiation Emergency Assistance Center/Training Site radiation accident registry over 1980-2013. We retrieved the reported overexposure cases, systematically extracted selected information, and performed a descriptive analysis. RESULTS 297 out of 5189 publications and reports and 194 records from the REAC/TS registry met our eligibility criteria. From these, 634 reported radiation accidents were retrieved, involving 2390 overexposed people, of whom 190 died from their overexposure. The number of reported cases has decreased for all types of radiation use, but the medical one. 64% of retrieved overexposure cases occurred with the use of radiation therapy and fluoroscopy. Additionally, the types of reported accidents differed significantly across regions. CONCLUSIONS This review provides an updated and broader view of reported radiation overexposures. It suggests an overall decline in reported radiation overexposures over 1980-2013. The greatest share of reported overexposures occurred in the medical fields using radiation therapy and fluoroscopy; this larger number of reported overexposures accidents indicates the potential need for enhanced quality assurance programs. Our data also highlights variations in characteristics of reported accidents by region. The main limitation of this study is the likely underreporting of radiation overexposures. Ensuring a comprehensive monitoring and reporting of radiation overexposures is paramount to inform and tailor prevention interventions to local needs.
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Affiliation(s)
- Karen Coeytaux
- Episight Consulting, Summit, New Jersey, United States of America
- * E-mail:
| | - Eric Bey
- Plastic and Reconstructive Surgery Department, Percy Military Hospital, Clamart, France
| | - Doran Christensen
- Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee, United States of America
| | - Erik S. Glassman
- Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee, United States of America
| | - Becky Murdock
- Radiation Emergency Assistance Center/Training Site (REAC/TS), Oak Ridge, Tennessee, United States of America
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Bolderston A, Di Prospero L, French J, Church J, Adams R. A Culture of Safety? An International Comparison of Radiation Therapists' Error Reporting. J Med Imaging Radiat Sci 2015; 46:16-22. [PMID: 31052059 DOI: 10.1016/j.jmir.2014.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 10/27/2014] [Accepted: 10/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND The process of radiation therapy planning and delivery is increasing in complexity, and errors that occur can have serious repercussions for patients. Many radiation therapy departments use incident learning systems (ILSs) to report, analyze, and learn from errors. The success of an ILS relies on a nonpunitive workplace culture in which practitioners are comfortable reporting errors. This study examines the error reporting culture of radiation therapists and dosimetrists in Canada and the United States. METHODS A survey assessing perceptions regarding communication among staff, comfort in error reporting, and associated obstacles was mailed to a national sample of 1,500 radiation therapists and 528 dosimetrists in the United States. A similar survey was sent electronically to 1,500 Canadian radiation therapists, and the results from both surveys were compared and summarized using descriptive statistics. RESULTS The quality of communication between radiation therapists and physicians, physicists, and administrators is good in both countries, but there are differences between the three groups, with administrators ranked lowest. There was better perceived communication between radiation therapists, physicians, and physicists in the US cohort. Both cohorts felt they had opportunities to speak to physicians, physicists, and administrators, but the US cohort felt they had better opportunities than the Canadians. Most respondents felt there was a system for reporting errors in their departments, but this was higher in the Canadian group (88% in the United States, 98% in Canada). The majority of respondents felt that they were encouraged and felt comfortable to report errors in the clinic, and this result was significantly higher in the Canadian group. The majority of respondents felt that they had not been reprimanded for reporting an error; more people reported knowing of other staff being reprimanded rather than themselves. The largest obstacles to error reporting in both cohorts were fear of reprimand, poor communication, and hierarchy. CONCLUSIONS The majority of staff in both countries feel that communication in their department is good and that there are adequate systems for error reporting. However, a number of respondents felt that they, or a colleague, had been reprimanded in the past, and there are still perceived barriers to the use of an ILS. There is still work to do on improving positive perceptions of error reporting and departmental communication.
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Affiliation(s)
- Amanda Bolderston
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada.
| | - Lisa Di Prospero
- Department of Radiation Oncology, Odette Cancer Centre at Sunnybrook and University of Toronto, Toronto, Ontario, Canada
| | - John French
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Jessica Church
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert Adams
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina, USA
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Mazeron R, Aguini N, Rivin Del Campo E, Dumas I, Gensse MC, Brusadin G, Lefkopoulos D, Deutsch E, Haie-Meder C. Implementation of the global risk analysis in pulsed-dose rate brachytherapy: methods and results. Cancer Radiother 2015; 19:89-97. [PMID: 25600666 DOI: 10.1016/j.canrad.2014.11.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Revised: 09/26/2014] [Accepted: 11/05/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To report the application of the global risk analysis (GRA) in the pulsed-dose rate (PDR) brachytherapy workflow. MATERIAL AND METHODS Analyses were led by a multidisciplinary working group established within the unit with the guidance of a quality engineer. First, a mapping of hazardous situations was developed as a result of interactions between the patient workflow for a treatment using PDR brachytherapy split into 51 sub-phases with a comprehensive list of the hazards that he/she faces (44). Interactions, when relevant, were sorted by level of priority: to be treated immediately, secondarily (the group is not entitled to treat the situation), or later (safe situation). Secondly, for each high priority dangerous situation, scenarios were developed to anticipate their potential consequences. Criticality was assessed, using likelihood and severity scales and a matrix, which allocated risks into categories: acceptable (C1), tolerable under control (C2) and unacceptable (C3). Then, corrective actions were proposed and planned when relevant, after assessment of their feasibility with a scale of effort. Finally, the criticality of the scenarios was reevaluated, taking into account the implementation of these actions, leading to a residual risk mapping, which could trigger additional proposals of actions. RESULTS Two thousand one hundred and eighty-four potential interactions between the list of hazards and the workflow were analyzed. Mapping of dangerous situations identified 213 relevant interactions, from which 61 were considered with high priority. One hundred and twenty-six scenarios were generated: 68 with a low criticality (74.3%), 58 with an intermediate score (25.7%). No scenario with the highest criticality was individualized. Twenty-one corrective actions were planned. Mapping of residual risk resulted in the disappearance of most C2 risks, leaving 5 C2 scenarios (4%), for which four monitoring indicators were implemented in addition to the corrected actions decided on. CONCLUSION The implementation of the GRA appeared feasible, and led to implement 21 corrective actions, based on scenarios and not on incidents.
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Affiliation(s)
- R Mazeron
- Radiation Oncology, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France.
| | - N Aguini
- Quality and risk Assessment, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - E Rivin Del Campo
- Radiation Oncology, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - I Dumas
- Medical physics, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - M-C Gensse
- Radiation Oncology, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - G Brusadin
- Radiation Oncology, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - D Lefkopoulos
- Medical physics, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - E Deutsch
- Radiation Oncology, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
| | - C Haie-Meder
- Radiation Oncology, Gustave-Roussy Cancer Campus Grand Paris, 114, rue Édouard-Vaillant, 97805 Villejuif cedex, France
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Krengli M, Masini L, Loi G. In reply to Skrobala and Malicki. Pract Radiat Oncol 2015; 5:e55. [PMID: 25567161 DOI: 10.1016/j.prro.2014.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 07/28/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Marco Krengli
- Chair of Radiotherapy, Department of Translational Medicine, University of "Piemonte Orientale", Novara, Italy.
| | - Laura Masini
- Department of Radiotherapy, University Hospital "Maggiore della Carità", Novara, Italy
| | - Gianfranco Loi
- Department of Medical Physics, University Hospital "Maggiore della Carità", Novara, Italy
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Han Z, Safavi-Naeini M, Alnaghy S, Cutajar DL, Guatelli S, Petasecca M, Franklin DR, Malaroda A, Carrara M, Bucci J, Zaider M, Lerch MLF, Rosenfeld AB. Radiation dose enhancement at tissue-tungsten interfaces in HDR brachytherapy. Phys Med Biol 2014; 59:6659. [DOI: 10.1088/0022-3727/59/21/6659] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Hoisak JDP, Pawlicki T, Kim GY, Fletcher R, Moore KL. Improving linear accelerator service response with a real- time electronic event reporting system. J Appl Clin Med Phys 2014; 15:4807. [PMID: 25207564 PMCID: PMC5711091 DOI: 10.1120/jacmp.v15i5.4807] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Revised: 05/08/2014] [Accepted: 04/24/2014] [Indexed: 11/23/2022] Open
Abstract
To track linear accelerator performance issues, an online event recording system was developed in-house for use by therapists and physicists to log the details of technical problems arising on our institution's four linear accelerators. In use since October 2010, the system was designed so that all clinical physicists would receive email notification when an event was logged. Starting in October 2012, we initiated a pilot project in collaboration with our linear accelerator vendor to explore a new model of service and support, in which event notifications were also sent electronically directly to dedicated engineers at the vendor's technical help desk, who then initiated a response to technical issues. Previously, technical issues were reported by telephone to the vendor's call center, which then disseminated information and coordinated a response with the Technical Support help desk and local service engineers. The purpose of this work was to investigate the improvements to clinical operations resulting from this new service model. The new and old service models were quantitatively compared by reviewing event logs and the oncology information system database in the nine months prior to and after initiation of the project. Here, we focus on events that resulted in an inoperative linear accelerator ("down" machine). Machine downtime, vendor response time, treatment cancellations, and event resolution were evaluated and compared over two equivalent time periods. In 389 clinical days, there were 119 machine-down events: 59 events before and 60 after introduction of the new model. In the new model, median time to service response decreased from 45 to 8 min, service engineer dispatch time decreased 44%, downtime per event decreased from 45 to 20 min, and treatment cancellations decreased 68%. The decreased vendor response time and reduced number of on-site visits by a service engineer resulted in decreased downtime and decreased patient treatment cancellations.
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44
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Mazeron R, Aguini N, Rivin E, Baudré A, Bour MS, Dumas I, Hubert F, Lopes S, Desroches A, Deutsch E, Lefkopoulos D, Bourhis J. Improving safety in radiotherapy: The implementation of the Global Risk Analysis method. Radiother Oncol 2014; 112:205-11. [DOI: 10.1016/j.radonc.2014.08.037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 08/01/2014] [Accepted: 08/27/2014] [Indexed: 11/26/2022]
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45
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Chang DW, Cheetham L, te Marvelde L, Bressel M, Kron T, Gill S, Tai KH, Ball D, Rose W, Silva L, Foroudi F. Risk factors for radiotherapy incidents and impact of an online electronic reporting system. Radiother Oncol 2014; 112:199-204. [DOI: 10.1016/j.radonc.2014.07.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2013] [Revised: 07/08/2014] [Accepted: 07/13/2014] [Indexed: 11/17/2022]
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Implementation of incident learning in the safety and quality management of radiotherapy: the primary experience in a new established program with advanced technology. BIOMED RESEARCH INTERNATIONAL 2014; 2014:392596. [PMID: 25140309 PMCID: PMC4129670 DOI: 10.1155/2014/392596] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/14/2014] [Indexed: 11/17/2022]
Abstract
Objective. To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program. Materials and Methods. With reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically established for reporting, investigating, and learning of individual incidents. The incidents that occurred in external beam radiotherapy from February, 2012, to February, 2014, were reported. Results. A total of 28 near misses and 5 incidents were reported. Among them, 5 originated in imaging for planning, 25 in planning, and 1 in plan transfer, commissioning, and delivery, respectively. One near miss/incident was classified as wrong patient, 7 wrong sites, 6 wrong laterality, and 5 wrong dose. Five reported incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, and inadequate training contributed to 19, 15, and 12 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4. Conclusion. Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety.
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Kertzscher G, Rosenfeld A, Beddar S, Tanderup K, Cygler JE. In vivo dosimetry: trends and prospects for brachytherapy. Br J Radiol 2014; 87:20140206. [PMID: 25007037 DOI: 10.1259/bjr.20140206] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The error types during brachytherapy (BT) treatments and their occurrence rates are not well known. The limited knowledge is partly attributed to the lack of independent verification systems of the treatment progression in the clinical workflow routine. Within the field of in vivo dosimetry (IVD), it is established that real-time IVD can provide efficient error detection and treatment verification. However, it is also recognized that widespread implementations are hampered by the lack of available high-accuracy IVD systems that are straightforward for the clinical staff to use. This article highlights the capabilities of the state-of-the-art IVD technology in the context of error detection and quality assurance (QA) and discusses related prospects of the latest developments within the field. The article emphasizes the main challenges responsible for the limited practice of IVD and provides descriptions on how they can be overcome. Finally, the article suggests a framework for collaborations between BT clinics that implemented IVD on a routine basis and postulates that such collaborations could improve BT QA measures and the knowledge about BT error types and their occurrence rates.
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Affiliation(s)
- G Kertzscher
- 1 Centre for Nuclear Technologies, Technical University of Denmark, Roskilde, Denmark
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48
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Masini L, Donis L, Loi G, Mones E, Molina E, Bolchini C, Krengli M. Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator. Pract Radiat Oncol 2014; 4:392-7. [PMID: 25407860 DOI: 10.1016/j.prro.2014.01.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 01/27/2014] [Accepted: 01/29/2014] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Laura Masini
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Laura Donis
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Gianfranco Loi
- Department of Medical Physics, University Hospital Maggiore della Carità, Novara, Italy
| | - Eleonora Mones
- Department of Medical Physics, University Hospital Maggiore della Carità, Novara, Italy
| | - Elisa Molina
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Cesare Bolchini
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy
| | - Marco Krengli
- Department of Radiotherapy, University Hospital Maggiore della Carità, Novara, Italy; Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
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Xia J, Mart C, Bayouth J. A computer aided treatment event recognition system in radiation therapy. Med Phys 2013; 41:011713. [DOI: 10.1118/1.4852895] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Kapur A, Goode G, Riehl C, Zuvic P, Joseph S, Adair N, Interrante M, Bloom B, Lee L, Sharma R, Sharma A, Antone J, Riegel A, Vijeh L, Zhang H, Cao Y, Morgenstern C, Montchal E, Cox B, Potters L. Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine. Front Oncol 2013; 3:305. [PMID: 24380074 PMCID: PMC3863912 DOI: 10.3389/fonc.2013.00305] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 12/02/2013] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Ajay Kapur
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Gina Goode
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Catherine Riehl
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Petrina Zuvic
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Sherin Joseph
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Nilda Adair
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Michael Interrante
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Beatrice Bloom
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Lucille Lee
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Rajiv Sharma
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Anurag Sharma
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Jeffrey Antone
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Adam Riegel
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Lili Vijeh
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Honglai Zhang
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Yijian Cao
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Carol Morgenstern
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Elaine Montchal
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Brett Cox
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
| | - Louis Potters
- Department of Radiation Medicine, North Shore-LIJ Cancer Institute, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY, USA
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