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Jacobson JO, Zerillo JA, Mulvey T, Stuver SO, Revette AC. Development of a taxonomy for characterising medical oncology-related patient safety and quality incidents: a novel approach. BMJ Open Qual 2022; 11:bmjoq-2022-001828. [PMID: 35793864 PMCID: PMC9260784 DOI: 10.1136/bmjoq-2022-001828] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/10/2022] [Indexed: 12/03/2022] Open
Affiliation(s)
- Joseph O Jacobson
- Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica Ann Zerillo
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Therese Mulvey
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sherri O Stuver
- Quality and Patient Safety, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Boston University School of Public Health, Boston, Massachusetts, USA
| | - Anna C Revette
- Population Science, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
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Nierer L, Walter F, Niyazi M, Shpani R, Landry G, Marschner S, von Bestenbostel R, Dinkel D, Essenbach G, Reiner M, Belka C, Corradini S. Radiotherapy in oncological emergencies: fast-track treatment planning. Radiat Oncol 2020; 15:215. [PMID: 32912293 PMCID: PMC7488151 DOI: 10.1186/s13014-020-01657-6] [Citation(s) in RCA: 4] [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: 07/17/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE To report on our clinical experience with a newly implemented workflow for radiotherapy (RT) emergency treatments, which allows for a fast treatment application outside the regular working-hours, and its clinical applicability. METHODS Treatment planning of 18 emergency RT patients was carried out using diagnostic computed tomography (CT) without a dedicated RT simulation CT. The cone-beam CT (CBCT) deviations of the first RT treatment were analyzed regarding setup accuracy. Furthermore, feasibility of the "fast-track" workflow was evaluated with respect to dose deviations caused by different Hounsfield unit (HU) to relative electron density (rED) calibrations and RT treatment couch surface shapes via 3D gamma index analysis of exemplary treatment plans. The dosimetric uncertainty introduced by different CT calibrations was quantified. RESULTS Mean patient setup vs. CBCT isocenter deviations were (0.49 ± 0.44) cm (x), (2.68 ± 1.63) cm (y) and (1.80 ± 1.06) cm (z) for lateral, longitudinal and vertical directions, respectively. Three out of four dose comparisons between the emergency RT plan calculated on the diagnostic CT and the same plan calculated on the treatment planning CT showed clinically acceptable gamma passing rates, when correcting for surface artifacts. The maximum difference of rED was 0.054, while most parts of the CT calibration curves coincided well. CONCLUSION In an emergency RT setting, the use of diagnostic CT data for treatment planning might be time-saving and was shown to be suitable for many cases, considering reproducibility of patient setup, accuracy of initial patient setup and accuracy of dose-calculation.
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Affiliation(s)
- Lukas Nierer
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Franziska Walter
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Maximilian Niyazi
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Roel Shpani
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Guillaume Landry
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Sebastian Marschner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Rieke von Bestenbostel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Dominika Dinkel
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Gabriela Essenbach
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Michael Reiner
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
| | - Stefanie Corradini
- Department of Radiation Oncology, University Hospital, LMU Munich, Marchioninistr. 15, 81377 Munich, Germany
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Piron O, Varfalvy N, Archambault L. Establishing action threshold for change in patient anatomy using EPID gamma analysis and PTV coverage for head and neck radiotherapy treatment. Med Phys 2018; 45:3534-3545. [PMID: 29896916 DOI: 10.1002/mp.13045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 05/24/2018] [Accepted: 05/31/2018] [Indexed: 02/28/2024] Open
Abstract
PURPOSE To present a new adaptive radiotherapy (ART) method based on relative gamma analysis and patient classification for the identification of anatomical changes that induce a sufficient dosimetric impact to affect the treatment delivery and require complete replanning. METHODS This retrospective study includes 55 patients treated for a head and neck cancer with IMRT, VMAT, or 3D conformal RT. Electronic Portal Imaging Device images for all treatment fields were acquired daily at every fraction. CBCTs were collected at least once a week. Gamma analysis was performed using the first fraction of the treatment as a reference once validated that it was delivered without error. Gamma analysis parameters (<γ>, standard deviation and the Top 1% γ) were used to define categories using statistic from a k-means clustering analysis. From these categories an action threshold was defined and correlated with dosimetric changes. For 23 of 55 patients, the V100% for PTV was computed for both, the planning CT and original contours deformed onto CBCT acquired at the last fraction. These values were then compared with 2D image relative γ-analysis of EPID images. Sensitivity and specificity of the method for the detection of dosimetric changes were computed. RESULTS Three categories indicating an increasing level of change with the planned treatment were identified. A threshold was established for which patients were at risk of deviation at <γ> = 0.42. From 23 recomputing plans, it has been confirmed that patients with a strong dosimetric impact were above this threshold, with a specificity of 0.80 and a sensitivity of 0.84. CONCLUSIONS The specificity and the sensitivity value confirmed the performance of the method to detect anatomical changes. The γ-analysis threshold correlated well with morphological changes that have a relevant dosimetric impact. Analysis of daily EPID images provides a method to identify patients at risk of deviation from their planned treatment and can support an early replanning decision.
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Affiliation(s)
- Ophélie Piron
- Department de Radio-oncologie, CHU de Quebec, 11 Côte du Palais, Quebec, QC, Canada
- Université Laval, 2325 Rue de l'Université, Ville de Québec, QC, G1V 0A6, Canada
| | - Nicolas Varfalvy
- Department de Radio-oncologie, CHU de Quebec, 11 Côte du Palais, Quebec, QC, Canada
- Université Laval, 2325 Rue de l'Université, Ville de Québec, QC, G1V 0A6, Canada
| | - Louis Archambault
- Department de Radio-oncologie, CHU de Quebec, 11 Côte du Palais, Quebec, QC, Canada
- Université Laval, 2325 Rue de l'Université, Ville de Québec, QC, G1V 0A6, Canada
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Romano KD, Trifiletti DM, Bauer-Nilsen K, Wages NA, Watkins WT, Read PW, Showalter TN. Clinical outcomes of helical conformal versus nonconformal palliative radiation therapy for axial skeletal metastases. Pract Radiat Oncol 2017; 7:e479-e487. [PMID: 28666907 DOI: 10.1016/j.prro.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 02/22/2017] [Accepted: 04/06/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE Palliative radiation therapy (RT) for bone metastases has traditionally been delivered with conventional, nonconformal RT (NCRT). Conformal RT (CRT) is potentially more complex and expensive than NCRT, but may reduce normal tissue dose and subsequently toxicity. In this retrospective analysis, we compared CRT with NCRT to investigate the association between conformality and toxicity. METHODS AND MATERIALS A retrospective analysis of patients receiving palliative RT for axial skeletal bone metastases from 2012 to 2014 was conducted. Patient and treatment characteristics were obtained including dosimetric variables, acute toxicity, and subjective pain during treatment and in the acute posttreatment period (≤60 days after completion). Statistical analyses included t tests, χ2 tests, and multivariate logistic regression. RESULTS A total of 179 patients and 254 bone metastases were identified (142 CRT, 112 NCRT). The CRT and NCRT groups were well matched for baseline characteristics (number of fractions, field size, treatment sites, and concurrent chemotherapy). In multivariate logistic regression models, technique (CRT vs NCRT) was not associated with development of acute toxicity. Regarding toxicity, Eastern Cooperative Oncology Group performance status and total dose were significantly associated with a higher rate of acute toxicity during RT (odds ratios, 0.649 and 1.129 and P = .027 and .044, respectively), and only a higher number of vertebral bodies in the treatment field was significantly associated with acute toxicity post-treatment (odds ratios, 1.219, P = .028). CRT was associated with improvement in bone pain during and posttreatment (P = .049 and .045, respectively). CONCLUSIONS Our results demonstrate no difference in acute toxicity following palliative RT with CRT compared with NCRT for painful bone metastases; however, treatment volume did predict for increased toxicity. Larger studies may further elucidate the value of CRT including the impact of dose escalation for bone metastases and differences in patient reported outcomes between RT techniques.
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Affiliation(s)
- Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia.
| | - Daniel M Trifiletti
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | | | - Nolan A Wages
- Department of Public Health Sciences, Division of Translational Research & Applied Statistics, University of Virginia, Charlottesville, Virginia
| | - William T Watkins
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Paul W Read
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
| | - Timothy N Showalter
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia
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Kim A, Ford E, Spraker M, Zeng J, Ermoian R, Jordan L, Kane G, Nyflot M. Are we making an impact with incident learning systems? Analysis of quality improvement interventions using total body irradiation as a model system. Pract Radiat Oncol 2017; 7:418-424. [PMID: 28688909 DOI: 10.1016/j.prro.2017.05.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/23/2017] [Accepted: 05/25/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Despite increasing interest in incident learning systems (ILS) to improve safety and quality in radiation oncology, little is known about interventions developed in response to safety data. We used total body irradiation (TBI) as a model system to study the effectiveness of interventions from our institutional ILS. METHODS AND MATERIALS Near-miss event reports specific to TBI were identified from a departmental ILS from March 2012 to December 2015. The near-miss risk index was rated at multidisciplinary review from 0 (no potential harm) to 4 (critical potential harm). Interventions were analyzed for effectiveness with a schema adapted from The Joint Commission and other agencies: "most reliable" (eg, forcing functions, automation), "somewhat reliable" (eg, checklists, standardization), and "least reliable" (eg, training, rules, procedures). Causal factors of each event were drawn from the casual factor schema used in radiation oncology ILS. RESULTS Of 4007 safety-related reports, 266 reports pertained to TBI. TBI reports had a somewhat higher proportion of high-risk events (near-miss risk index 3-4) compared with non-TBI reports (25% vs 17%, P = .0045). A total of 117 interventions were implemented. The reliability indicators for the interventions were: most reliable (11% of interventions), somewhat reliable (17%), and least reliable (72%). Interventions were more likely to be applied to high-risk events (54% vs 41%, P = .03). There was a pattern of high-reliability interventions with increased risk score of events. Events involving human error (eg, slips) and equipment/information technology lent themselves more often to high-reliability interventions. Events related to communication, standardization, and training were associated with low-reliability interventions. CONCLUSIONS Over a 3.5-year period, 117 quality improvement strategies were developed for TBI based on ILS. Interventions were more likely to be applied to high-risk events and high-risk events were more likely to be associated with high-quality interventions. These results may be useful to institutions seeking to develop interventions based on ILS data.
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Affiliation(s)
- Aileen Kim
- Department of Radiation Oncology, University of Washington, Seattle, Washington.
| | - Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Matthew Spraker
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Jing Zeng
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Ralph Ermoian
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Loucille Jordan
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Gabrielle Kane
- Department of Radiation Oncology, University of Washington, Seattle, Washington
| | - Matthew Nyflot
- Department of Radiation Oncology, University of Washington, Seattle, Washington
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Gensheimer MF, Zeng J, Carlson J, Spady P, Jordan L, Kane G, Ford EC. Influence of planning time and treatment complexity on radiation therapy errors. Pract Radiat Oncol 2016; 6:187-193. [DOI: 10.1016/j.prro.2015.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 09/16/2015] [Accepted: 10/25/2015] [Indexed: 11/30/2022]
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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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