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Finn M, Walsh A, Rafter N, Mellon L, Chong HY, Naji A, O'Brien N, Williams DJ, McCarthy SE. Effect of interventions to improve safety culture on healthcare workers in hospital settings: a systematic review of the international literature. BMJ Open Qual 2024; 13:e002506. [PMID: 38719514 PMCID: PMC11086522 DOI: 10.1136/bmjoq-2023-002506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 04/17/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND In an era of safety systems, hospital interventions to build a culture of safety deliver organisational learning methodologies for staff. Their benefits to hospital staff are unknown. We examined the literature for evidence of staff outcomes. Research questions were: (1) how is safety culture defined in studies with interventions that aim to enhance it?; (2) what effects do interventions to improve safety culture have on hospital staff?; (3) what intervention features explain these effects? and (4) what staff outcomes and experiences are identified? METHODS AND ANALYSIS We conducted a mixed-methods systematic review of published literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search was conducted in MEDLINE, EMBASE, CINAHL, Health Business Elite and Scopus. We adopted a convergent approach to synthesis and integration. Identified intervention and staff outcomes were categorised thematically and combined with available data on measures and effects. RESULTS We identified 42 articles for inclusion. Safety culture outcomes were most prominent under the themes of leadership and teamwork. Specific benefits for staff included increased stress recognition and job satisfaction, reduced emotional exhaustion, burnout and turnover, and improvements to working conditions. Effects were documented for interventions with longer time scales, strong institutional support and comprehensive theory-informed designs situated within specific units. DISCUSSION This review contributes to international evidence on how interventions to improve safety culture may benefit hospital staff and how they can be designed and implemented. A focus on staff outcomes includes staff perceptions and behaviours as part of a safety culture and staff experiences resulting from a safety culture. The results generated by a small number of articles varied in quality and effect, and the review focused only on hospital staff. There is merit in using the concept of safety culture as a lens to understand staff experience in a complex healthcare system.
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Affiliation(s)
- Mairead Finn
- Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Aisling Walsh
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Natasha Rafter
- Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Lisa Mellon
- Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Hui Yi Chong
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Abdullah Naji
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Niall O'Brien
- Library Services, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David J Williams
- Department of Geriatric and Stroke Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Siobhan Eithne McCarthy
- Graduate School of Healthcare Management, Royal College of Surgeons in Ireland, Dublin, Ireland
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2
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Chowdhury IH, Garg R, Huber KE, Stambaugh NP, Stambaugh C. Implementation of a patient safety training program in radiation oncology residency: A pilot study. J Appl Clin Med Phys 2024; 25:e14286. [PMID: 38358132 DOI: 10.1002/acm2.14286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 12/04/2023] [Accepted: 01/19/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE An educational program using Radiation Oncology-Incident Learning System (RO-ILS) was developed to improve safety culture and training for radiation oncology (RO) residents. METHODS The program included a pre-training assessment, interactive training, integration of residents into quality assurance meetings, and a post-training assessment over a 3 month rotation. RESULTS Twelve residents completed the safety training program. Pre-training assessment mean scores (five-point scale) of experience with Incident Learning Systems (ILS), root-cause analysis (RCA), failure-mode and effect analysis (FMEA), safety training, and culture were 2.3, 2.8, 2.0, 4.0, and 4.4, respectively. Post-training assessment showed a significant increase in ILS 4.0 (p < 0.001), RCA 3.8 (p = 0.008), and FMEA 3.3 (p = 0.006) and safety culture (4.8, p = 0.043). Additionally, residents were anonymously surveyed ≥ 10 months after graduation to determine the long-term value of the program. The overall assessment from the graduated residents indicates that this education is valued by RO in many institutions. The majority of the residents are either currently utilizing or plan to utilize the information gained in this program in their new institutions. CONCLUSIONS We report a successful implementation of a safety training program in a RO residency with significant improvements in self-reported confidence with the concepts of ILS, RCA, and FMEA and an improved perception of safety culture. This program can be implemented across all residency programs.
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Affiliation(s)
- Imran H Chowdhury
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Radiation Oncology, Oncology Hematology Care, Inc., Cincinnati, Ohio, USA
| | - Rashi Garg
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts, USA
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathryn E Huber
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Nathaniel P Stambaugh
- Department of Math and Science, Southfield School, Dexter, Brookline, Massachusetts, USA
| | - Cassandra Stambaugh
- Department of Radiation Oncology, Tufts University School of Medicine, Boston, Massachusetts, USA
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3
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Blackler N, Bradley KE, Kelly C, Murphy S, Cross C, Kirby M. A national survey of the radiotherapy dosimetrist workforce in the UK. Br J Radiol 2022; 95:20220459. [PMID: 36063424 PMCID: PMC9793486 DOI: 10.1259/bjr.20220459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 07/14/2022] [Accepted: 07/25/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To undertake a national survey of the Radiotherapy Dosimetrist workforce within the UK; examining different attributes and experiences, comparing results with published evidence within the literature. METHODS A national, anonymised survey was undertaken between Dec 2020 and end of Feb 2021; employing a mixed-methods approach and blend of closed, open-ended answer choices and free-text comments. Questions included range of training routes and job titles; registration status; job tasks and engagement with Continuing Professional Development (CPD). RESULTS A total of 223 individuals responded. Nearly half were trained via therapeutic radiography; approximately, a fifth through a clinical technologist/physics routes. Most (70%) had Dosimetrist in their job title. Nearly 70% were statutorily registered, and almost a fifth were in the voluntary register of Clinical Technologists. Most job tasks were in treatment planning - with 57% spending over 70% of their time there. Most notably, 29% were not involved in any CPD scheme. No published evidence showed the same aspects identified here. CONCLUSIONS Our survey showed a unique profile of the Radiotherapy Dosimetrist workforce in the UK, with a variety of training routes and statutory registration status. Nearly, a third were not engaged in a CPD scheme - adding to the current discussion that perhaps all Dosimetrists should be statutorily registered, for ensuring safe and effective clinical practice. ADVANCES IN KNOWLEDGE A novel and unique national survey of Dosimetrists working in Radiotherapy in the UK is presented, leading to new insights into current training routes, registration status, job tasks and CPD engagement and needs.
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Affiliation(s)
| | | | | | | | | | - Mike Kirby
- The University of Liverpool, Liverpool, UK
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4
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Haukåsen OA, Hermanrud I. Creating a lean mind-set: Change of practice towards early treatment. MANAGEMENT LEARNING 2022. [DOI: 10.1177/13505076221122152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This paper reports the findings of a qualitative study on lean implementation viewed as an organisational learning process. By using a scaffolding framework, we investigate the ways in which human resource development facilitates learning among clinicians. This study contributes to the temporary role of human resource development in learning processes within multi-disciplinary professional groups. We identify scaffolding activities from which we have identified three human resource development practices: phase 1 – cognitive scaffolding, in which human resource development acts as a ‘mindsetter’ that aims to motivate the learning of lean in relation to the clinicians’ practices; phase 2 – peer-to-peer scaffolding through ‘doing’ lean, in which human resource development performs the role of an ‘experience creator’ who creates knowledge engagement between peers – in order to put lean into practice; and phase 3 – fading of the scaffolding, in which human resource development performs the role of a ‘delegator’ who transfers the responsibility to the clinicians to promote learning. This contributes to our understanding of how knowledge is negotiated in a multidisciplinary context. We contribute to the learning literature by emphasising how learning trajectories are initiated by learning initiatives, highlighting the role limitations of human resource development in this context, and demonstrating how a new learning tension arises between different versions of ‘lean’ in the organisation.
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5
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Volpini ME, Lekx-Toniolo K, Mahon R, Buckley L. The impact of COVID-19 workflow changes on radiation oncology incident reporting. J Appl Clin Med Phys 2022; 23:e13742. [PMID: 35932177 PMCID: PMC9539311 DOI: 10.1002/acm2.13742] [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: 01/14/2022] [Revised: 06/17/2022] [Accepted: 07/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background The Ottawa Hospital's Radiation Oncology program maintains the Incident Learning System (ILS)—a quality assurance program that consists of report submissions of errors and near misses arising from all major domains of radiation. In March 2020, the department adopted workflow changes to optimize patient and provider safety during the COVID‐19 pandemic. Purpose In this study, we analyzed the number and type of ILS submissions pre‐ and postpandemic precautions to assess the impact of COVID‐19‐related workflow changes. Methods ILS data was collected over six one‐year time periods between March 2016 and March 2021. For all time periods, the number of ILS submissions were counted. Each ILS submission was analyzed for the specific treatment domain from which it arose and its root cause, explaining the impetus for the error or near miss. Results Since the onset of COVID‐19‐related workflow changes, the total number of ILS submissions have reduced by approximately 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to prepandemic data. There was also an increase in the proportion of “treatment planning” ILS submissions and a 50% reduction in the proportion of “decision to treat” ILS submissions compared to previous years. Root cause analysis revealed there were more incidents attributable to “poor, incomplete, or unclear documentation” during the pandemic year. Conclusions COVID‐19 workflow changes were associated with fewer ILS submissions, but a relative increase in submissions stemming from poor documentation and communication. It is imperative to analyze ILS submission data, particularly in a changing work environment, as it highlights the potential and realized mistakes that impact patient and staff safety.
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Affiliation(s)
- Matthew E Volpini
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | | | - Robert Mahon
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Lesley Buckley
- Division of Radiation Oncology, The Ottawa Hospital, Ottawa, ON, Canada
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6
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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: 3] [Impact Index Per Article: 0.8] [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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Mazur LM, Adams R, Mosaly PR, Stiegler MP, Nuamah J, Adapa K, Chera B, Marks LB. Impact of Simulation-Based Training on Radiation Therapists' Workload, Situation Awareness, and Performance. Adv Radiat Oncol 2020; 5:1106-1114. [PMID: 33305071 PMCID: PMC7718555 DOI: 10.1016/j.adro.2020.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/29/2020] [Accepted: 09/22/2020] [Indexed: 11/29/2022] Open
Abstract
Purpose This study aimed to assess the impact of simulation-based training intervention on radiation therapy therapist (RTT) mental workload, situation awareness, and performance during routine quality assurance (QA) and treatment delivery tasks. Methods and Materials As part of a prospective institutional review board-approved study, 32 RTTs completed routine QA and treatment delivery tasks on clinical scenarios in a simulation laboratory. Participants, randomized to receive (n = 16) versus not receive (n = 16) simulation-based training had pre- and postintervention assessments of mental workload, situation awareness, and performance. We used linear regression models to compare the postassessment scores between the study groups while controlling for baseline scores. Mental workload was quantified subjectively using the NASA Task Load Index. Situation awareness was quantified subjectively using the situation awareness rating technique and objectively using the situation awareness global assessment technique. Performance was quantified based on procedural compliance (adherence to preset/standard QA timeout tasks) and error detection (detection and correction of embedded treatment planning errors). Results Simulation-based training intervention was associated with significant improvements in overall performance (P < .01), but had no significant impact on mental workload or subjective/objective quantifications of situation awareness. Conclusions Simulation-based training might be an effective tool to improve RTT performance of QA-related tasks.
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Affiliation(s)
- Lukasz M Mazur
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina.,School of Information and Library Sciences, University of North Carolina at Chapel Hill, North Carolina.,Carolina Health Informatics Program, University of North Carolina at Chapel Hill, North Carolina
| | - Robert Adams
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Prithima R Mosaly
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina.,School of Information and Library Sciences, University of North Carolina at Chapel Hill, North Carolina.,Carolina Health Informatics Program, University of North Carolina at Chapel Hill, North Carolina
| | | | - Joseph Nuamah
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Karthik Adapa
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina.,Carolina Health Informatics Program, University of North Carolina at Chapel Hill, North Carolina
| | - Bhishamjit Chera
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina, Chapel Hill, North Carolina
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8
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Kundu P, Jung OS, Valle LF, Edmondson AC, Agazaryan N, Hegde J, Steinberg M, Raldow A. Missing the Near Miss: Recognizing Valuable Learning Opportunities in Radiation Oncology. Pract Radiat Oncol 2020; 11:e256-e262. [PMID: 32971273 DOI: 10.1016/j.prro.2020.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE "Near miss" events are valuable low-cost learning opportunities in radiation oncology as they do not result in patient harm and are more pervasive than adverse events that do. Near misses vary depending on the presence of a latent error of behavior or process, and the presence of an enabling condition predisposing the patient to harm. These nuanced distinctions across near miss types can elicit different cognitive biases affecting the recognition of near misses as learning opportunities. We define near miss types in radiation oncology and explore the differential perceptions among radiation oncology staff. METHODS AND MATERIALS Six event types were defined based on attributes of latent error and enabling conditions: "hit," "potential hit," "almost happened," "fortuitous catch," "could have happened," and "process-based catch." These events were illustrated with an example of a patient receiving pacemaker cardiac clearance before radiation treatment. A survey assessing (1) success versus failure of an event and (2) willingness to report the event was administered to a radiation oncology department using the pacemaker example. Mean scores for each near miss type were compared. RESULTS Ninety-five staff members (74%) completed the survey. Perceived success scores and willing-to-report scores significantly differed by near miss type (P = .042 for success ratings; P < .0001 for willingness to report). "Could have happened" events were viewed as less successful and were more likely to be reported than "almost happened" events (P < .0001). CONCLUSIONS Cognitive biases appear to influence whether and how near miss types are recognized as report-worthy. Education of near miss types and engaging staff for quality improvement may improve recognition.
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Affiliation(s)
- Palak Kundu
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California.
| | | | - Luca F Valle
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | | | - Nzhde Agazaryan
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - John Hegde
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Michael Steinberg
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
| | - Ann Raldow
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles, California
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9
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Mullins BT, Mazur L, Dance M, McGurk R, Schreiber E, Marks LB, Shen CJ, Lawrence MV, Chera BS. Common Error Pathways in CyberKnife™ Radiation Therapy. Front Oncol 2020; 10:1077. [PMID: 32733802 PMCID: PMC7360810 DOI: 10.3389/fonc.2020.01077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/29/2020] [Indexed: 12/02/2022] Open
Abstract
Purpose/Objectives: Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) may be considered “high risk” due to the high doses per fraction. We analyzed CyberKnife™ (CK) SRS and SBRT-related incidents that were prospectively reported to our in-house incident learning system (ILS) in order to identify severity, contributing factors, and common error pathways. Material and Methods: From 2012 to 2019, 221 reported incidents related to the 4,569 CK fractions delivered (5.8%) were prospectively analyzed by our multi-professional Quality and Safety Committee with regard to severity, contributing factors, as well as the location where the incident occurred (tripped), where it was discovered (caught), and the safety barriers that were traversed (crossed) on the CK process map. Based on the particular step in the process map that incidents tripped, we categorized incidents into general error pathways. Results: There were 205 severity grade 1–2 (did not reach patient or no clinical impact), 11 grade 3 (clinical impact unlikely), 5 grade 4 (altered the intended treatment), and 0 grade 5–6 (life-threatening or death) incidents, with human performance being the most common contributing factor (79% of incidents). Incidents most commonly tripped near the time when the practitioner requested CK simulation (e.g., pre-CK simulation fiducial marker placement) and most commonly caught during the physics pre-treatment checklist. The four general error pathways included pre-authorization, billing, and scheduling issues (n= 119); plan quality (n= 30); administration of IV contrast during simulation or pre-medications during treatment (n= 22); and image guidance (n= 12). Conclusion: Most CK incidents led to little or no patient harm and most were related to billing and scheduling issues. Suboptimal human performance appeared to be the most common contributing factor to CK incidents. Additional study is warranted to develop and share best practices to reduce incidents to further improve patient safety.
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Affiliation(s)
- Brandon T Mullins
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Lukasz Mazur
- Division of Healthcare Engineering, Department of Radiation Oncology, University of North Carolina School of Medicine, Chapel Hill, NC, United States.,Carolina Health Informatics Program, School of Information and Library Science, University of North Carolina, Chapel Hill, NC, United States
| | - Michael Dance
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Ross McGurk
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Eric Schreiber
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Michael V Lawrence
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
| | - Bhishamjit S Chera
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, United States
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10
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Mosaly PR, Adams R, Tracton G, Dooley J, Adapa K, Nuamah JK, Marks LB, Mazur LM. Impact of Workspace Design on Radiation Therapist Technicians' Physical Stressors, Mental Workload, Situation Awareness, and Performance. Pract Radiat Oncol 2020; 11:e3-e10. [PMID: 32707097 DOI: 10.1016/j.prro.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 06/03/2020] [Accepted: 07/06/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Our purpose was to assess the effect of workspace configuration on radiation therapists' (RTs) physical stressors, mental workload (WL), situational awareness (SA), and performance during routine treatment delivery tasks in a simulated environment. METHODS AND MATERIALS Fourteen RTs were randomized to 2 workspace configurations while performing 4 simulated scenarios: current (not ergonomically optimized; n = 7) and enhanced (ergonomically optimized, n = 7). Physical stressors were objectively assessed using a rapid upper limb assessment tool. Mental WL was measured at the end of each simulated scenario subjectively using the NASA Task-Load Index and objectively throughout the scenario using eye-tracking metrics (pupil diameter and blink rate). SA was measured at the end of each simulated scenario subjectively using the situation awareness and review technique. Performance was measured objectively via assessment of time-out compliance, error detection, and procedural compliance. Analysis of variance was used to test the effect of workspace configuration on physical stressors, mental WL, SA, and performance. RESULTS The enhanced configuration significantly reduced physical stressors (rapid upper limb assessment; P < .01) and resulted in a higher rate of time-out compliance (P = .01) compared with current workspace configuration. No significant effect on other metrics was measured. CONCLUSIONS Our results suggest that an ergonomically designed workspace may minimize physical stressors and improve the performance of RTs.
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Affiliation(s)
- Prithima R Mosaly
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; School of Information and Library Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.
| | - Robert Adams
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Gregg Tracton
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - John Dooley
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Karthik Adapa
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; School of Information and Library Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph K Nuamah
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lawrence B Marks
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Lukasz M Mazur
- Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; School of Information and Library Sciences, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Carolina Health Informatics Program, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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11
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Wright JL, Terezakis SA, Ford E. Safety First: Developing and Deploying a System to Promote Safety and Quality in Your Clinic. Pract Radiat Oncol 2020; 11:92-100. [PMID: 32450366 DOI: 10.1016/j.prro.2020.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
The terms "safety and quality" (SAQ) have become inextricably linked, highly used terms that together encompass a wide range of parameters within medical departments. Safety has always been a priority in radiation oncology; quality assurance has been foundational to our practice. Despite this increased focus and attention on SAQ, the "what" of SAQ remains ill-defined, largely because of the vast number of indicators that fall under this umbrella. Similarly, the "how" of developing and maintaining the highest standards of SAQ is not formulaic and varies based on the unique setting of individual practices. There are several excellent resources available to inform SAQ in radiation oncology, including the American Society for Radiation Oncology's "Safety Is No Accident," which provides an overview of safety and quality standards and resources. This review is intended as a brief summary of key considerations, with the goal of providing a practical framework and context for improving or developing a SAQ program in radiation oncology practices. We believe that the following 10 key elements, drawn from numerous reports that have appeared over the last decade examining this topic, should be considered when conceptualizing a practice-based approach to SAQ: establishing a strong safety culture; establishing a structured program for safety and quality; establishing up-to-date, relevant, and accessible policies and procedures; a system for peer review; systems to assess and reduce risk; an educational program focused on safety and quality; development and review of meaningful quality metrics; utilization of a physics quality control system; well-defined models for staffing, training, and professional development; and finally, validation from external bodies via accreditations and audits. These 10 items are addressed herein.
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Affiliation(s)
- Jean L Wright
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins University, Baltimore, Maryland.
| | | | - Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, Washington
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12
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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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Judy GD, Lindsay DP, Gu D, Mullins BT, Mosaly PR, Marks LB, Chera BS, Mazur LM. Incorporating Human Factors Analysis and Classification System (HFACS) Into Analysis of Reported Near Misses and Incidents in Radiation Oncology. Pract Radiat Oncol 2019; 10:e312-e321. [PMID: 31526899 DOI: 10.1016/j.prro.2019.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 08/30/2019] [Accepted: 09/06/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Human factors analysis and classification system (HFACS) is a framework for investigation into causation of human errors. We herein assess whether radiation oncology professionals, with brief training, can conduct HFACS on reported near misses or safety incidents (NMSIs) in a reliable (eg, with a high level of agreement) and practical (eg, timely and with user satisfaction) manner. METHODS AND MATERIALS We adapted a classical HFACS framework by selecting and modifying main headings, subheadings, and nano-codes that were most likely to apply to radiation oncology settings. The final modified HFACS included 3 main headings, 8 subheadings, and 20 nano-codes. The modified HFACS was first tested in a simulated trial on 8 NMSI and was analyzed by 5 to 10 radiation oncology professionals, with 2 endpoints: (1) agreement among participants at the main-heading, subheading, and nano-code level, and (2) time to complete the analysis. We then performed a prospective trial integrating this approach into a weekly NMSI review meeting, with 10 NMSIs analyzed by 8 to 13 radiation oncology professionals with the same endpoints, while also collecting survey data on participants' satisfaction. RESULTS In the simulated trial, agreement among participants was 85% on the main headings, 73% on the subheadings, and 70% on the nano-codes. Participants needed, on average, 16.4 minutes (standard deviation, 5.7 minutes) to complete an analysis. In the prospective trial, agreement between participants was 81% on the main headings, 75% on the subheadings, and 74% on the nano-codes. Participants needed, on average, 8.3 minutes (standard deviation, 4.7 minutes) to complete an analysis. The average satisfaction with the proposed HFACS approach was 3.9 (standard deviation 1.0) on a scale from 1 to 5. CONCLUSIONS This study demonstrates that, after relatively brief training, radiation oncology professionals were able to perform HFACS analysis in a reliable and timely manner and with a relatively high level of satisfaction.
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Affiliation(s)
| | - Daniel P Lindsay
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
| | - Deen Gu
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Brandon T Mullins
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Prithima R Mosaly
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lawrence B Marks
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Bhishamjit S Chera
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Lukasz M Mazur
- Department of Radiation Oncology and Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Liu S, Bush KK, Bertini J, Fu Y, Lewis JM, Pham DJ, Yang Y, Niedermayr TR, Skinner L, Xing L, Beadle BM, Hsu A, Kovalchuk N. Optimizing efficiency and safety in external beam radiotherapy using automated plan check (APC) tool and six sigma methodology. J Appl Clin Med Phys 2019; 20:56-64. [PMID: 31423729 PMCID: PMC6698761 DOI: 10.1002/acm2.12678] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 05/20/2019] [Accepted: 06/11/2019] [Indexed: 11/13/2022] Open
Abstract
PURPOSE To develop and implement an automated plan check (APC) tool using a Six Sigma methodology with the aim of improving safety and efficiency in external beam radiotherapy. METHODS The Six Sigma define-measure-analyze-improve-control (DMAIC) framework was used by measuring defects stemming from treatment planning that were reported to the departmental incidence learning system (ILS). The common error pathways observed in the reported data were combined with our departmental physics plan check list, and AAPM TG-275 identified items. Prioritized by risk priority number (RPN) and severity values, the check items were added to the APC tool developed using Varian Eclipse Scripting Application Programming Interface (ESAPI). At 9 months post-APC implementation, the tool encompassed 89 check items, and its effectiveness was evaluated by comparing RPN values and rates of reported errors. To test the efficiency gains, physics plan check time and reported error rate were prospectively compared for 20 treatment plans. RESULTS The APC tool was successfully implemented for external beam plan checking. FMEA RPN ranking re-evaluation at 9 months post-APC demonstrated a statistically significant average decrease in RPN values from 129.2 to 83.7 (P < .05). After the introduction of APC, the average frequency of reported treatment-planning errors was reduced from 16.1% to 4.1%. For high-severity errors, the reduction was 82.7% for prescription/plan mismatches and 84.4% for incorrect shift note. The process shifted from 4σ to 5σ quality for isocenter-shift errors. The efficiency study showed a statistically significant decrease in plan check time (10.1 ± 7.3 min, P = .005) and decrease in errors propagating to physics plan check (80%). CONCLUSIONS Incorporation of APC tool has significantly reduced the error rate. The DMAIC framework can provide an iterative and robust workflow to improve the efficiency and quality of treatment planning procedure enabling a safer radiotherapy process.
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Affiliation(s)
- Shi Liu
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | - Karl K. Bush
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | | | - Yabo Fu
- Department of Radiation OncologyWashington University School of MedicineSt. LouisMOUSA
| | | | - Daniel J. Pham
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | - Yong Yang
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | | | - Lawrie Skinner
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | - Lei Xing
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | - Beth M. Beadle
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
| | - Annie Hsu
- Department of Radiation OncologyStanford UniversityStanfordCAUSA
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Ford EC, Moran JM, Kim G, Schubert L, Rong Y. Parallel perspectives for building sustainable safety initiatives. J Appl Clin Med Phys 2019; 20:5-10. [PMID: 31365185 PMCID: PMC6698756 DOI: 10.1002/acm2.12690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Eric C. Ford
- Department of Radiation OncologyUniversity of WashingtonSeattleWashington
| | - Jean M. Moran
- Radiation OncologyUniversity of MichiganAnn ArborMichigan
| | - Gwe‐Ya Kim
- Radiation Medicine and Applied SciencesUniversity of California, San DiegoSan DiegoCalifornia
| | - Leah Schubert
- Radiation OncologyUniversity of Colorado School of MedicineAuroraColorado
| | - Yi Rong
- Radiation OncologyUniversity of California DavisSacramentoCalifornia
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Durable Improvement in Patient Safety Culture Over 5 Years With Use of High-volume Incident Learning System. Pract Radiat Oncol 2019; 9:e407-e416. [DOI: 10.1016/j.prro.2019.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 11/23/2022]
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Howell C, Tracton G, Amos A, Chera B, Marks LB, Mazur LM. Predicting Radiation Therapy Process Reliability Using Voluntary Incident Learning System Data. Pract Radiat Oncol 2019; 9:e210-e217. [PMID: 30529794 DOI: 10.1016/j.prro.2018.11.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 11/19/2018] [Accepted: 11/29/2018] [Indexed: 10/27/2022]
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Gopan O, Smith WP, Chvetsov A, Hendrickson K, Kalet A, Kim M, Nyflot M, Phillips M, Young L, Novak A, Zeng J, Ford E. Utilizing simulated errors in radiotherapy plans to quantify the effectiveness of the physics plan review. Med Phys 2018; 45:5359-5365. [DOI: 10.1002/mp.13242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- Olga Gopan
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Wade P. Smith
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Alexei Chvetsov
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Kristi Hendrickson
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Alan Kalet
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Minsun Kim
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Matthew Nyflot
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Mark Phillips
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Lori Young
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Avrey Novak
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Jing Zeng
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Eric Ford
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
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Schubert L, Petit J, Vinogradskiy Y, Peters R, Towery J, Stump B, Westerly D, Ridings J, Kneeland P, Liu A. Implementation and operation of incident learning across a newly-created health system. J Appl Clin Med Phys 2018; 19:298-305. [PMID: 30225861 PMCID: PMC6236828 DOI: 10.1002/acm2.12447] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 07/15/2018] [Accepted: 07/16/2018] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The purpose of this work is to describe our experience launching an expanded incident learning system for patient safety and quality that takes into account aspects beyond therapeutic dose delivery, specifically imaging/simulation incidents, medical care incidents, and operational issues. METHODS Our ILS was designed for a newly created health system comprised of a midsized academic hospital and two smaller community hospitals. The main design goal was to create a highly sensitive system to capture as much information throughout the department as possible. Reports were classified according to incidents and near misses involving therapeutic radiation, imaging/simulation, and patient care (not involving radiation), unsafe conditions, operational issues, and accolades/suggestions. Reports were analyzed according to impact on various steps in the process of care. Actions made in response to reports were assessed and characterized by intervention reliability. RESULTS A total of 1125 reports were submitted in the first 23 months. For all three departments, therapeutic radiation incidents and near misses consisted of less than one-third of all reports submitted. For the midsized academic department, operational issues and unsafe conditions comprised the largest percentage of reports (70%). Although the majority of reports impacted steps related to the technical aspects of treatment (simulation, planning, and treatment delivery), 20% impacted other steps such as scheduling or clinic visits. More than 160 actions were performed in response to reports. Of these actions, 63 were quality improvement interventions to improve practices, while 97 were learning actions for raising awareness. CONCLUSIONS We have developed an ILS that identifies issues related to the entire process of care delivery in radiation oncology, as evidenced by frequent and varied reported events. By identifying a broad spectrum of issues in a department, opportunities for improvement can be identified.
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Affiliation(s)
- Leah Schubert
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Josh Petit
- University of Colorado Health Poudre Valley Hospital, Fort Collins, CO, USA
| | - Yevgeniy Vinogradskiy
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Rick Peters
- University of Colorado Health Poudre Valley Hospital, Fort Collins, CO, USA
| | - Jack Towery
- University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - Bryan Stump
- University of Colorado Health Poudre Valley Hospital, Fort Collins, CO, USA
| | - David Westerly
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jane Ridings
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA.,University of Colorado Health Memorial Hospital, Colorado Springs, CO, USA
| | - Patrick Kneeland
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Arthur Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, CO, USA
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20
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Ford EC, Evans SB. Incident learning in radiation oncology: A review. Med Phys 2018; 45:e100-e119. [PMID: 29419944 DOI: 10.1002/mp.12800] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 11/06/2022] Open
Abstract
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.
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Affiliation(s)
- Eric C Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA, 98195, USA
| | - Suzanne B Evans
- Department of Radiation Oncology, Yale University, New Haven, CT, 06510, USA
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Mazur LM, Marks LB, McLeod R, Karwowski W, Mosaly P, Tracton G, Adams RD, Hoyle L, Das S, Chera B. Promoting safety mindfulness: Recommendations for the design and use of simulation-based training in radiation therapy. Adv Radiat Oncol 2018; 3:197-204. [PMID: 29904745 PMCID: PMC6000160 DOI: 10.1016/j.adro.2018.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Revised: 12/19/2017] [Accepted: 01/19/2018] [Indexed: 11/29/2022] Open
Abstract
There is a need to better prepare radiation therapy (RT) providers to safely operate within the health information technology (IT) sociotechnical system. Simulation-based training has been preemptively used to yield meaningful improvements during providers' interactions with health IT, including RT settings. Therefore, on the basis of the available literature and our experience, we propose principles for the effective design and use of simulated scenarios and describe a conceptual framework for a debriefing approach to foster successful training that is focused on safety mindfulness during RT professionals' interactions with health IT.
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Affiliation(s)
- Lukasz M. Mazur
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
- Carolina Health Informatics Program, School of Information and Library Science, University of North Carolina, Chapel Hill, North Carolina
| | - Lawrence B. Marks
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | | | - Waldemar Karwowski
- Industrial Engineering and Management Systems, College of Engineering and Computer Science, University of Central Florida, Orlando, Florida
| | - Prithima Mosaly
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
- Carolina Health Informatics Program, School of Information and Library Science, University of North Carolina, Chapel Hill, North Carolina
| | - Gregg Tracton
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Robert D. Adams
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Lesley Hoyle
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Shiva Das
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Bhishamjit Chera
- Division of Healthcare Engineering, Department of Radiation Oncology, School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Ezzell G, Chera B, Dicker A, Ford E, Potters L, Santanam L, Weintraub S. Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety. Pract Radiat Oncol 2018; 8:123-132. [DOI: 10.1016/j.prro.2017.10.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 10/09/2017] [Accepted: 10/15/2017] [Indexed: 11/26/2022]
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Judy GD, Mosaly PR, Mazur LM, Tracton G, Marks LB, Chera BS. Identifying Factors and Root Causes Associated With Near-Miss or Safety Incidents in Patients Treated With Radiotherapy: A Case-Control Analysis. J Oncol Pract 2017. [DOI: 10.1200/jop.2017.021121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose: To identify factors associated with a near-miss or safety incident (NMSI) in patients undergoing radiotherapy and identify common root causes of NMSIs and their relationship with incident severity. Methods: We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with an NMSI (n = 200; incident group) and a similar group of control patients (n = 200) matched in time, without an NMSI. A root cause and incident severity were determined for each NMSI. Univariable and multivariable analyses were performed to determine which specific factors were contributing to NMSIs. Multivariable logistic regression was used to determine root causes of NMSIs and their relationship with incident severity. Results: NMSIs were associated with the following factors: head and neck sites (odds ratio [OR], 5.2; P = .01), image-guided intensity-modulated radiotherapy (OR, 3; P = .009), daily imaging (OR, 7; P < .001), and tumors staged as T2 (OR, 3.3; P = .004). Documentation and scheduling errors were the most common root causes (29%). Communication errors were more likely to affect patients ( P < .001), and technical treatment delivery errors were most associated with a higher severity score ( P = .005). Conclusion: Several treatment- and disease-specific factors were found to be associated with an NMSI. Overall, our results suggest that complexity (eg, head and neck, image-guided intensity-modulated radiotherapy, and daily imaging) might be a contributing factor for an NMSI. This promotes an idea of developing a more dedicated and robust quality assurance system for complex cases and highlights the importance of a strong reporting system to support a safety culture.
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Affiliation(s)
- Gregory D. Judy
- University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Lukasz M. Mazur
- University of North Carolina School of Medicine, Chapel Hill, NC
| | - Gregg Tracton
- University of North Carolina School of Medicine, Chapel Hill, NC
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Abstract
Although many error pathways are common to both stereotactic body radiation therapy (SBRT) and conventional radiation therapy, SBRT presents a special set of challenges including short treatment courses and high-doses, an enhanced reliance on imaging, technical challenges associated with commissioning, special resource requirements for staff and training, and workflow differences. Emerging data also suggest that errors occur at a higher rate in SBRT treatments. Furthermore, when errors do occur they often have a greater effect on SBRT treatments. Given these challenges, it is important to understand and employ systematic approaches to ensure the quality and safety of SBRT treatment. Here, we outline the pathways by which error can occur in SBRT, illustrated through a series of case studies, and highlight 9 specific well-established tools to either reduce error or minimize its effect to the patient or both.
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Affiliation(s)
- Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Sonja Dieterich
- Department of Radiation Oncology, University of California, Davis, CA
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Improving patient safety and workflow efficiency with standardized pretreatment radiation therapist chart reviews. Pract Radiat Oncol 2017; 7:339-345. [PMID: 28341319 DOI: 10.1016/j.prro.2017.01.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/23/2017] [Accepted: 01/30/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Radiation therapists play a critical role in ensuring patient safety; however, they are sometimes given insufficient time to perform quality assurance (QA) of a patient's treatment chart and documentation before the start of treatment. In this work, we show the benefits of introducing a formal therapist prestart QA checklist, completed in a quiet space well in advance of treatment, into our workflow. METHODS AND MATERIALS A therapist prestart QA checklist was created by analyzing in-house variance reports and treatment unit delays over 6 months. Therapists were then given dedicated time and workspace to perform their checks within the dosimetry office of our department. The effectiveness of the checklist was quantified by recording the percentage of charts that underwent QA before treatment, the percentage of charts with errors needing intervention, and treatment unit delays during a nearly 2-year period. The frequency and types of errors found by the prestart QA were also recorded. RESULTS Through the use of therapist prestart QA, instances of treatment unit delays were reduced by up to a factor of 9 during the first year of the program. At the outset of this new initiative, nearly 40% of charts had errors requiring intervention, with the majority being scheduling related. With upstream workflow changes and automation, this was reduced over the period of a year to about 10%. CONCLUSIONS The number of treatment unit delays was dramatically reduced by using a formal therapist prestart QA checklist completed well in advance of treatment. The data collected via the checklist continue to be used for further quality improvement efforts.
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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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Peterka Novak J. Gradnja strokovnih zmogljivosti zaposlenih v zdravstveni negi. OBZORNIK ZDRAVSTVENE NEGE 2016. [DOI: 10.14528/snr.2016.50.1.76] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Uvod: Izobraževanja prispevajo k strokovnemu znanju. Vplivajo na produktivnost in prožnost zaposlenih, izide zdravstvene oskrbe, kakovost obravnave, zadovoljstvo pacientov, svojcev in zaposlenih. Namen raziskave je bil ugotoviti mnenje udeležencev o izvedenih seminarjih in predlagati usmeritve in priporočila.
Metode: Izvedena je bila kvantitativna metoda raziskovanja v letu 2014. Vprašalnik so udeleženci (n = 242) izpolnili na dan seminarja. Razdeljen je bil na štiri sklope: ocena dogodka (kraj, čas, tema, obveščenost, registracija, organizacija, gradivo), ocena strokovnih vsebin in ocena predavatelja, ocena časa izvedbe predavanj, učnih delavnic, razprav, podajanje mnenj udeležencev. Pridobljene podatke smo opisno analizirali. Izračunane so bile frekvence, odstotek, preizkus χ2 z razmerjem verjetij.
Rezultati: Med seminarji obstajajo statistično pomembne razlike v kakovosti gradiv (χ2 = 34,082, p 0,018). V zvezi z vsebinami obstajajo statistično pomembne razlike v izpolnitvi pričakovanj udeležencev glede na starost v skupini od 31 do 40 let (χ2 = 9,735, p > 0,021).
Diskusija in zaključek: Udeleženci so imeli visok nivo zadovoljstva z organizacijo, izborom tem in vsebinami. Izboljšave so potrebne pri pripravi gradiv, pri izboru kompetentnih predavateljev in v trajanju delavnic.
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Marks LB, Pawlicki TA, Hayman JA. Learning to Appreciate Swiss Cheese and Other Industrial Engineering Concepts. Pract Radiat Oncol 2015; 5:277-281. [PMID: 26362704 DOI: 10.1016/j.prro.2015.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 07/21/2015] [Indexed: 12/26/2022]
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