Trend analysis of radiation therapy incidents over seven years

Causal analysis of radiotherapy safety incidents based on a hybrid model of HFACS and Bayesian network

Objective

This research investigates the role of human factors of all hierarchical levels in radiotherapy safety incidents and examines their interconnections.

Methods

Utilizing the human factor analysis and classification system (HFACS) and Bayesian network (BN) methodologies, we created a BN-HFACS model to comprehensively analyze human factors, integrating the hierarchical structure. We examined 81 radiotherapy incidents from the radiation oncology incident learning system (RO-ILS), conducting a qualitative analysis using HFACS. Subsequently, parametric learning was applied to the derived data, and the prior probabilities of human factors were calculated at each BN-HFACS model level. Finally, a sensitivity analysis was conducted to identify the human factors with the greatest influence on unsafe acts.

Results

The majority of safety incidents reported on RO-ILS were traced back to the treatment planning phase, with skill errors and habitual violations being the primary unsafe acts causing these incidents. The sensitivity analysis highlighted that the condition of the operators, personnel factors, and environmental factors significantly influenced the occurrence of incidents. Additionally, it underscored the importance of organizational climate and organizational process in triggering unsafe acts.

Conclusion

Our findings suggest a strong association between upper-level human factors and unsafe acts among radiotherapy incidents in RO-ILS. To enhance radiation therapy safety and reduce incidents, interventions targeting these key factors are recommended.

ACPSEM position paper: pre-treatment patient specific plan checks and quality assurance in radiation oncology

The Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) has not previously made recommendations outlining the requirements for physics plan checks in Australia and New Zealand. A recent workforce modelling exercise, undertaken by the ACPSEM, revealed that the workload of a clinical radiation oncology medical physicist can comprise of up to 50% patient specific quality assurance activities. Therefore, in 2022 the ACPSEM Radiation Oncology Specialty Group (ROSG) set up a working group to address this issue. This position paper authored by ROSG endorses the recommendations of the American Association of Physicists in Medicine (AAPM) Task Group 218, 219 and 275 reports with some contextualisation for the Australia and New Zealand settings. A few recommendations from other sources are also endorsed to complete the position.

Feasibility study of a scintillation sheet-based detector for fluence monitoring during external photon beam radiotherapy

PURPOSE

This study evaluated the properties of a scintillation sheet-based dosimetry system for beam monitoring with high spatial resolution, including the effects of this system on the treatment beam. The dosimetric characteristics and feasibility of this system for clinical use were also evaluated.

METHODS

The effects of the dosimetry system on the beam were evaluated by measuring the percentage depth doses, dose profiles, and transmission factors. Fifteen treatment plans were created, and the influence of the dosimetry system on these clinical treatment plans was evaluated. The performance of the system was assessed by determining signal linearity, dose rate dependence, and reproducibility. The feasibility of the system for clinical use was evaluated by comparing intensity distributions with reference intensity distributions verified by quality assurance.

RESULTS

The spatial resolution of the dosimetry system was found to be 0.43 mm/pixel when projected to the isocenter plane. The dosimetry system attenuated the intensity of 6 MV beams by about 1.1%, without affecting the percentage depth doses and dose profiles. The response of the dosimetry system was linear, independent of the dose rate used in the clinic, and reproducible. Comparison of intensity distributions of evaluation treatment fields with reference intensity distributions showed that the 1%/1 mm average gamma passing rate was 99.6%.

CONCLUSIONS

The dosimetry system did not significantly alter the beam characteristics, indicating that the system could be implemented by using only a transmission factor. The dosimetry system is clinically suitable for monitoring treatment beam delivery with higher spatial resolution than other transmission detectors.

Safety in radiation oncology (SAFRON): Learning about incident causes and safety barriers in external beam radiotherapy

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.

Multi-Institutional Stereotactic Body Radiation Therapy Incident Learning: Evaluation of Safety Barriers Using a Human Factors Analysis and Classification System

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.

Development of a dosimetry system for therapeutic X-rays using a flexible amorphous silicon thin-film solar cell with a scintillator screen

PURPOSE

To evaluate the dosimetric characteristics and applications of a dosimetry system composed of a flexible amorphous silicon thin-film solar cell and scintillator screen (STFSC-SS) for therapeutic X-rays.

METHODS

The real-time dosimetry system was composed of a flexible a-Si thin film solar cell (0.2-mm thick), a scintillator screen to increase its efficiency, and an electrometer to measure the generated charge. The dosimetric characteristics of the developed system were evaluated, including its energy dependence, dose linearity, and angular dependence. Calibration factors for the signal measured by the system and absorbed dose-to-water were obtained by setting reference conditions. The application and correction accuracy of the developed system were evaluated by comparing the absorbed dose-to-water measured using a patient treatment beam with that measured using the ion chamber.

RESULTS

The responses of STFSC-SS to energy, field size, depth, and source-to-surface distance (SSD) were more dependent on measurement conditions than were the responses of the ion chamber, although the former dependence was due to the scintillator screen, not the solar cell. The signal of STFSC-SS were also dependent on dose rate, while the responses of solar cell alone and scintillator screen were not dependent on dose rate. The scintillator screen reduced the output of solar cell 6 and 15 MV by 0.60% and 0.55%, respectively. The absorbed doses-to-water measured using STFSC-SS for patient treatment beam differed by 0.4% compared to those measured using the ionization chamber. The uncertainties of the developed system for 6 and 15 MV photon beams were 1.8% and 1.7%, respectively, confirming the accuracy and applicability of this system.

CONCLUSIONS

; The thin film solar cell-based detector developed in this study can accurately measure absorbed dose-to-water. The increased signal resulting from the use of the scintillator screen is advantageous for measuring low doses and stable signal output. In addition, this system is flexible, making it applicable to curved surfaces such as a patient's body, and is cost-effective. This article is protected by copyright. All rights reserved.

Incident review in radiation oncology

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.

Handling of Incidents in the Clinical Application of Ionizing Radiation in Diagnostic and Interventional Radiology - a Multi-center Study

PURPOSE

 According to the German legislation and regulation of radiation protection, i. e. Strahlenschutzgesetz und Strahlenschutzverordnung (StrlSchG and StrlSchV), which came into force on 31^st 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.

How often does it happen? A review of unintended, unnecessary and unavoidable high-dose radiation exposures

High-dose radiation exposures of humans occur every year around the world, and may lead to harmful tissue reactions. This review aims to look at the available information sources that can help answering the question of how often these events occur yearly on a global scale. In the absence of comprehensive databases of global occurrence, publications on radiation accidents in all uses of radiation and on rates of high-dose events in different medical uses of radiation have been reviewed. Most high-dose radiation exposures seem to occur in the medical uses of radiation, reflecting the high number of medical exposures performed. In therapeutic medical uses, radiation doses are purposely often given at levels known to cause deterministic effects, and there is a very narrow range in which the medical practitioner can operate without causing severe unacceptable outcomes. In interventional medical uses, there are scenarios in which the radiation dose given to a patient may reach or exceed a threshold for skin effects, where this radiation dose may be unavoidable, considering all benefits and risks as well as benefits and risks of any alternative procedures. Regardless of if the delivered dose is unintended, unnecessary or unavoidable, there are estimates published of the rates of high-dose events and of radiation-induced tissue injuries occurring in medical uses. If this information is extrapolated to a global scenario, noting the inherent limitations in doing so, it does not seem unreasonable to expect that the global number of radiation-induced injuries every year may be in the order of hundreds, likely mainly arising from medical uses of radiation, and in particular from interventional fluoroscopy procedures and external beam radiotherapy procedures. These procedures are so frequently employed throughout the world that even a very small rate of radiation-induced injuries becomes a substantial number when scaled up to a global level.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The role of surface-guided radiation therapy for improving patient safety

Emerging data indicates SGRT could improve safety and quality by preventing errors in its capacity as an independent system in the treatment room. The aim of this work is to investigate the utility of SGRT in the context of safety and quality. Three incident learning systems (ILS) were reviewed to categorize and quantify errors that could have been prevented with SGRT: SAFRON (International Atomic Energy Agency), UW-ILS (University of Washington) and AvIC (Skåne University Hospital). A total of 849/9737 events occurred during the pre-treatment review/verification and treatment stages. Of these, 179 (21%) events were predicted to have been preventable with SGRT. The most common preventable events were wrong isocentre (43%) and incorrect accessories (34%), which appeared at comparable rates among SAFRON and UW-ILS. The proportion of events due to wrong accessories was much smaller in the AvIC ILS, which may be attributable to the mandatory use of SGRT in Sweden. Several case scenarios are presented to demonstrate that SGRT operates as a valuable complement to other quality-improvement tools routinely used in radiotherapy. Cases are noted in which SGRT itself caused incidents. These were mostly related to workflow issues and were of low severity. Severity data indicated that events with the potential to be mitigated by SGRT were of higher severity for all categories except wrong accessories. Improved vendor integration of SGRT systems within the overall workflow could further enhance its clinical utility. SGRT is a valuable tool with the potential to increase patient safety and treatment quality in radiotherapy.

Usability testing of radiotherapy systems as a medical device evaluation tool to inform hospital procurement decision-making

PURPOSE

Poor usability designs of radiotherapy systems can contribute to use errors and adverse events. Therefore, we evaluated the usability of two radiotherapy systems through radiation therapists' performance, workload, and experience that can inform hospital procurement decision-making about the selection of appropriate radiotherapy system for radiation therapist use.

METHODS

We performed a comparative usability study for two radiotherapy systems through user testing. Thirty radiation therapists participated in our study, in which four typical operational tasks were performed in two tested radiotherapy systems. User performance was measured by task completion time and completion difficulty level. User workloads were measured by perceived and physiological workload using NASA-TLX questionnaires and eye motion data. User experience was measured by the USE questionnaire.

RESULTS

Significantly less task completion time and an easier task completion difficulty level were shown with the Varian Trilogy than with the XHA600E. The study results suggest that higher perceived and physiological workloads were experienced with the XHA600E than with the Varian Trilogy. Radiation therapists reported better user experience with the Varian Trilogy than with the XHA600E. Five paired t-tests regarding user performance, user workload, and user experience between the Varian Trilogy and the XHA600E were performed, showing that the Varian Trilogy radiotherapy system has a better usability design than the XHA600E radiotherapy system.

CONCLUSIONS

Based on study results, we confirmed that the Varian Trilogy radiotherapy system has a better usability design than the XHA600E radiotherapy system. Furthermore, the study results provide valuable evidence for hospital procurement decision-making regarding the selection of a suitable radiotherapy system for radiation therapists to use.

Critical success factors for implementation of an incident learning system in radiation oncology department

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.

The journey towards safer radiotherapy: are we on a road to nowhere?

Background:

Harnessing available knowledge and learning from our errors are prerequisites of delivering on the challenge of improving patient safety. Towards Safer Radiotherapy, published in 2008, was a response from the UK’s (UK) radiotherapy community to concerns arising from high profile errors. The report was a driver for the development of a national reporting and learning system for radiotherapy.

Materials and methods:

A literature review was conducted covering the years from 2009 to 2020. Search terms used were radiotherapy errors, patient safety, incident learning, human factors and trend analysis. A total of 10 papers reported recommendations or implementation of changes to service delivery models following systematic error analysis. None of these were from UK service providers.

Conclusions:

Twelve years on from the publication of Towards Safer Radiotherapy, there is little evidence of impact on safety culture within the UK radiotherapy community. Although the UK has a large radiotherapy error dataset, there remain unanswered questions about the impact on the safety culture in radiotherapy.

Quality management in radiation therapy: A 15 year review of incident reporting in two integrated cancer centres

•

Fifteen years of reported incidents were reviewed.

•

Overall reduction in incident severity overtime identified.

•

New technology associated to reduced incident severity.

•

Reporting culture associated to reporting rates.

•

Taxonomy changes required to improve ISL and incident classification.

Fifteen years of reported incidents were reviewed to provide insight into the effectiveness of an Incident Learning System (ISL). The actual error rate over the 15 years was 1.3 reported errors per 1000 treatment attendances. Incidents were reviewed using a regression model. The average number of incidents per year and the number of incidents per thousand attendances declined over time. Two seven-year periods were considered for analysis and the average for the first period (2005–2011) was 6 reported incidents per 1000 attendances compared to 2 incidents for the later period (2012–2018), p < 0.05. SAC 1 and SAC 2 errors have reduced over time and the reduction could be attributed to the quality assurance aspect of IGRT where the incident is identified prior to treatment delivery rather than after, reducing the severity of any potential incidents. The reasoning behind overall reduction in incident reporting over time is unclear but may be associated to quality and technology initiatives, issues with the ISL itself or a change in the staff reporting culture.

Evaluation and improvement the safety of total marrow irradiation with helical tomotherapy using repeat failure mode and effects analysis

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.

[A Human Factors Study Using VTA for Incident Cases in Radiotherapy]

In recent years, workload has increased with higher precision of radiotherapy. Although both efficiency and thoroughness of treatment are crucial, in such conditions, human error is easy to occur. In this study, five incident cases that occurred in four facilities were studied and analyzed from the viewpoint of human factors that contribute to errors using variation tree analysis. We also analyzed resilience (the ability to return to one's original state even if the system deviates from a stable state), which has attracted attention in recent safety research. There were potential factors represented by patient factors in all cases. These factors caused deviations from standard operations, and incidents occurred due to unfamiliar situations and operations. Furthermore, in four of the five cases, the cause of the incident was a resilience action or judgment that was deemed to have required "some sort of ingenuity or adjustment." It was found that human error occurred due to multiple simultaneous occurrences of potential factors, i.e., patient and human factors such as high workload, impatience, and work interruptions. A reduction in human errors can be achieved by avoiding time pressure and multitasking, creating work environment and working conditions that make resilience work well, revising ambiguous rules and procedures, and promoting standardized working methods.

Implementation and operation of incident learning across a newly-created health system

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.

The Second Victim Phenomenon: Perspective of Canadian Radiation Therapists

INTRODUCTION

Clinical incidents are an unfortunate reality in the health care system. Patients and their families are the first victims of these incidents. The health care providers involved in the error are considered the second victims. This research aimed to evaluate the level of awareness of the second victim phenomenon (SVP) in Canadian radiation therapists, determine the post-incident emotional and physical reactions experienced, and determine the existing and/or recommended systems for support.

METHODS

Mixed method design comprised two phases. In phase I, Canadian radiation therapists were invited to view an informational presentation about the SVP and complete an online survey. In phase II, participants partook in an online discussion forum.

RESULTS

Survey results indicate that 31% of respondents were previously aware of the SVP and 86% of respondents report having been involved in a clinical incident. In addition, the results confirm that Canadian radiation therapists who have been involved in health care-related incidents do experience emotional and physical reactions. Most respondents indicated they lacked appropriate organizational support to help them recover from the clinical incident. Support from a colleague is the preferred method of support immediately after the incident. Finally, survey respondents indicated a clear desire for implementation of defined processes for postclinical incident supports.

DISCUSSION

The reported level of awareness of the SVP surprised the authors as it was anticipated to be lower; however, there is an obvious need for greater knowledge of the subject. Reported frequency of involvement in a clinical incident as well as the post-clinical reactions experienced are comparable for other health care providers as indicated in the literature. Survey results revealed that emotional and physical reactions were experienced to a greater degree in those unfamiliar with the SVP, indicating potential value to adding an educational component to radiation therapist's training programs as well as on the job training for staff in the workforce. Most respondents requested specific methods of support for recovery after a clinical incident. In addition, an unexpected number of radiation therapists indicated the need for a "no-blame" work environment, which was an unanticipated finding.

CONCLUSION

This study highlights the lack of awareness of the SVP in Canadian radiation therapists. It identifies the gap between the needs of the second victims and the perceived lack of supports offered by their facilities. This issue is important for organizations wanting to positively manage clinical incidents and create a culture of safety for the patients and employees.

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

AIM

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

BACKGROUND

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Incident learning in radiation oncology: A review

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

A patient safety education program in a medical physics residency

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.

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Brachytherapy patient safety events in an academic radiation medicine program

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.

Cost-effective immobilization for whole brain radiation therapy

To investigate the inter‐ and intra‐fraction motion associated with the use of a low‐cost tape immobilization technique as an alternative to thermoplastic immobilization masks for whole‐brain treatments. The results of this study may be of interest to clinical staff with severely limited resources (e.g., in low‐income countries) and also when treating patients who cannot tolerate standard immobilization masks. Setup reproducibility of eight healthy volunteers was assessed for two different immobilization techniques. (a) One strip of tape was placed across the volunteer's forehead and attached to the sides of the treatment table. (b) A second strip was added to the first, under the chin, and secured to the table above the volunteer's head. After initial positioning, anterior and lateral photographs were acquired. Volunteers were positioned five times with each technique to allow calculation of inter‐fraction reproducibility measurements. To estimate intra‐fraction reproducibility, 5‐minute anterior and lateral videos were taken for each technique per volunteer. An in‐house software was used to analyze the photos and videos to assess setup reproducibility. The maximum intra‐fraction displacement for all volunteers was 2.8 mm. Intra‐fraction motion increased with time on table. The maximum inter‐fraction range of positions for all volunteers was 5.4 mm. The magnitude of inter‐fraction and intra‐fraction motion found using the “1‐strip” and “2‐strip” tape immobilization techniques was comparable to motion restrictions provided by a thermoplastic mask for whole‐brain radiotherapy. The results suggest that tape‐based immobilization techniques represent an economical and useful alternative to the thermoplastic mask.

Nature of Medical Malpractice Claims Against Radiation Oncologists

PURPOSE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSIONS

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

Hazards and incidents: Detection and learning in radiation medicine, a comparison of 2 educational interventions

PURPOSE

Interprofessional, educational live simulations were compared with group discussion-based exercises in terms of their ability to improve radiation medicine trainees' ability to detect hazards and incidents and understand behaviors that may prevent them.

METHODS AND MATERIALS

Trainees and recent graduates of radiation therapy, medical physics, and radiation oncology programs were recruited and randomized to either a simulation-based or group discussion-based training intervention. Participants engaged in hazard and incident detection, analysis, and a discussion of potential preventive measures and the concept of the "highly reliable team." A video examination tool modeled on actual incidents, using 5-minute videos created by faculty, students, and volunteers, was created to test hazard and incident recognition ability before and after training. Hazard and incident detection sensitivity and specificity analyses were conducted, and a survey of the participants' and facilitators' perceptions was conducted.

RESULTS

Twenty-seven participants were assigned to the simulation (n = 15) or discussion group (n = 12). Hazard and incident-detection sensitivity ranged from 0.04 to 0.56 before and 0.04 to 0.35 after training for the discussion and simulation groups, respectively. The pre- and posttraining difference in sensitivity between groups was 0.03 (P = .75) for the minimum and 0.33 (P = .034) for the maximum reaction time. Participant perceptions of the training's educational value in a variety of domains ranged from a mean score of 6.58 to 8.17 and 7 to 8.07 for the discussion and simulation groups, respectively. Differences were not statistically significant. Twenty-six of the 27 participants indicated that they would recommend this event to a colleague.

CONCLUSIONS

Participants' ability to detect hazards and incidents as portrayed in 5-minute videos in this study was low both before and after training, and simulation-based training was not superior to discussion-based training. However, levels of satisfaction and perceptions of the training's educational value were high, especially with simulation-based training.

Adaptive Dose Escalation using Serial Four-dimensional Positron Emission Tomography/Computed Tomography Scans during Radiotherapy for Locally Advanced Non-small Cell Lung Cancer

AIMS

Computed tomography (CT)-based radiotherapy dose escalation for locally advanced non-small cell lung cancer (LA-NSCLC) has had limited success. In this planning study, we investigated the potential for adaptive dose escalation using respiratory-gated 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography scans (4DPET/4DCT) acquired before and during a course of chemoradiotherapy (CRT).

MATERIALS AND METHODS

We prospectively enrolled patients with LA-NSCLC receiving curative intent CRT. Radiotherapy was delivered using intensity-modulated radiotherapy (IMRT) using the week 0 4DCT scan. Three alternative, dose-escalated IMRT plans were developed offline based on the week 0, 2 and 4 4DPET/4DCT scans. The FDG-avid primary (PET-T) and nodal disease (PET-N) volumes defined by the 50% of maximum standard uptake value threshold were dose escalated to as high as possible while respecting organ at risk constraints.

RESULTS

Thirty-two patients were recruited, 27 completing all scans. Twenty-five patients (93%) were boosted successfully above the clinical plan doses at week 0, 23 (85%) at week 2 and 20 (74%) at week 4. The median dose received by 95% of the planning target volume (D95) at week 0, 2 and 4 to PET-T were 74.4 Gy, 75.3 Gy and 74.1 Gy and to PET-N were 74.3 Gy, 71.0 Gy and 69.5 Gy.

CONCLUSIONS

Using 18F-FDG-4DPET/4DCT, it is feasible to dose escalate both primary and nodal disease in most patients. Choosing week 0 images to plan a course with an integrated boost to PET-avid disease allows for more patients to be successfully dose escalated with the highest boost dose.

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

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

Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department

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.

Monitoring external beam radiotherapy using real-time beam visualization

PURPOSE

To characterize the performance of a novel radiation therapy monitoring technique that utilizes a flexible scintillating film, common optical detectors, and image processing algorithms for real-time beam visualization (RT-BV).

METHODS

Scintillating films were formed by mixing Gd2O2S:Tb (GOS) with silicone and casting the mixture at room temperature. The films were placed in the path of therapeutic beams generated by medical linear accelerators (LINAC). The emitted light was subsequently captured using a CMOS digital camera. Image processing algorithms were used to extract the intensity, shape, and location of the radiation field at various beam energies, dose rates, and collimator locations. The measurement results were compared with known collimator settings to validate the performance of the imaging system.

RESULTS

The RT-BV system achieved a sufficient contrast-to-noise ratio to enable real-time monitoring of the LINAC beam at 20 fps with normal ambient lighting in the LINAC room. The RT-BV system successfully identified collimator movements with sub-millimeter resolution.

CONCLUSIONS

The RT-BV system is capable of localizing radiation therapy beams with sub-millimeter precision and tracking beam movement at video-rate exposure.

RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience

PURPOSE

Incident learning is a critical tool to improve patient safety. The Patient Safety and Quality Improvement Act of 2005 established essential legal protections to allow for the collection and analysis of medical incidents nationwide.

METHODS AND MATERIALS

Working with a federally listed patient safety organization (PSO), the American Society for Radiation Oncology and the American Association of Physicists in Medicine established RO-ILS: Radiation Oncology Incident Learning System (RO-ILS). This paper provides an overview of the RO-ILS background, development, structure, and workflow, as well as examples of preliminary data and lessons learned. RO-ILS is actively collecting, analyzing, and reporting patient safety events.

RESULTS

As of February 24, 2015, 46 institutions have signed contracts with Clarity PSO, with 33 contracts pending. Of these, 27 sites have entered 739 patient safety events into local database space, with 358 events (48%) pushed to the national database.

CONCLUSIONS

To establish an optimal safety culture, radiation oncology departments should establish formal systems for incident learning that include participation in a nationwide incident learning program such as RO-ILS.

Regional cancer centre demonstrates voluntary conformity with the national Radiation Oncology Practice Standards

Radiation Oncology Practice Standards have been developed over the last 10 years and were published for use in Australia in 2011. Although the majority of the radiation oncology community supports the implementation of the standards, there has been no mechanism for uniform assessment or governance. North Coast Cancer Institute's public radiation oncology service is provided across three main service centres on the north coast of NSW. With a strong focus on quality management, we embraced the opportunity to demonstrate conformity with the Radiation Oncology Practice Standards. The Local Health District's Clinical Governance units were engaged to perform assessments of our conformity with the standards and this was signed off as complete on 16 December 2013. The process of demonstrating conformity with the Radiation Oncology Practice Standards has enhanced the culture of quality in our centres. We have demonstrated that self-assessment utilising trained auditors is a viable method for centres to demonstrate conformity. National implementation of the Radiation Oncology Practice Standards will benefit individual centres and the broader radiation oncology community to improve the service delivered to our patients.

Bayesian network models for error detection in radiotherapy plans

The purpose of this study is to design and develop a probabilistic network for detecting errors in radiotherapy plans for use at the time of initial plan verification. Our group has initiated a multi-pronged approach to reduce these errors. We report on our development of Bayesian models of radiotherapy plans. Bayesian networks consist of joint probability distributions that define the probability of one event, given some set of other known information. Using the networks, we find the probability of obtaining certain radiotherapy parameters, given a set of initial clinical information. A low probability in a propagated network then corresponds to potential errors to be flagged for investigation. To build our networks we first interviewed medical physicists and other domain experts to identify the relevant radiotherapy concepts and their associated interdependencies and to construct a network topology. Next, to populate the network's conditional probability tables, we used the Hugin Expert software to learn parameter distributions from a subset of de-identified data derived from a radiation oncology based clinical information database system. These data represent 4990 unique prescription cases over a 5 year period. Under test case scenarios with approximately 1.5% introduced error rates, network performance produced areas under the ROC curve of 0.88, 0.98, and 0.89 for the lung, brain and female breast cancer error detection networks, respectively. Comparison of the brain network to human experts performance (AUC of 0.90 ± 0.01) shows the Bayes network model performs better than domain experts under the same test conditions. Our results demonstrate the feasibility and effectiveness of comprehensive probabilistic models as part of decision support systems for improved detection of errors in initial radiotherapy plan verification procedures.

Team-based clinical simulation in radiation medicine: value to attitudes and perceptions of interprofessional collaboration

Introduction

Simulation has been effective for changing attitudes towards team-based competencies in many areas, but its role in teaching interprofessional collaboration (IPC) in radiation medicine (RM) is unknown. This study reports on feasibility and IPC outcomes of a team-based simulation event; ‘Radiation Medicine Simulation in Learning Interprofessional Collaborative Experience’ (RM SLICE).

Methods

Radiation therapy (RTT), medical physics (MP) and radiation oncology (RO) trainees in a single academic department were eligible. Scheduled closure of a modern RM clinic allowed rotation of five high-fidelity cases in three 105-minute timeslots. A pre/post-survey design evaluated learner satisfaction and interprofessional perceptions. Scales included the Readiness for Interprofessional Learning Scale (RIPLS), UWE Entry Level Interprofessional Questionnaire (UWEIQ), Trainee Test of Team Dynamics and Collaborative Behaviours Scale (CBS).

Results

Twenty-one trainees participated; six ROs (28·57%), six MPs (28·57%) and nine RTTs (42·86%). All cases were conducted, resolved and debriefed within the allotted time. Twenty-one complete sets (100%) of evaluations were returned. Participants reported limited interaction with other professional groups before RM SLICE. Perceptions of team functioning and value of team interaction in ‘establishing or improving the care plan’ were high for all cases, averaging 8·1/10 and 8·9/10. Average CBS scores were 70·4, 71·9 and 69·5, for the three cases, scores increasing between the first and second case for 13/21 (61·9%) participants. RIPLS and UWEIQ scores reflected positive perceptions both pre- and post-event, averaging 83·5 and 85·2 (RIPLS) and 60·6 and 55·7 (UWEIQ), respectively. For all professions for both scales, the average change in score reflected improved IP perceptions, with agreement between scales for 15/20 (75·0%) participants. Overall, perception of IPC averaged 9·14/10, as did the importance of holding such an event annually.

Conclusions

Team-based simulation is feasible in RM and appears to facilitate interprofessional competency-building in high-acuity clinical situations, reflecting positive perceptions of IPC.

A Culture of Safety? An International Comparison of Radiation Therapists' Error Reporting

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.

Working conditions, job strain and work engagement among Belgian radiation oncologists

PURPOSE

This national survey has measured the working conditions, work engagement, job strain, burn out, and the negative work-home interaction among Belgian radiation oncologists with validated questionnaires. In fact, previous studies had in general shown an interest to burn out and its association with working conditions among oncology workers, but not focused on radiation oncologists in particular. Moreover, few studies concerned work engagement and its association with working conditions although this could be important in preventing burn out.

METHODS

We used the WOrking Conditions and Control Questionnaire, the Positive and Negative Occupational States Inventory, the Maslach Burn out Inventory, and the negative work-home interaction subscale of the Survey Work-home Interaction Nijmegen. One open question asked about problematic job situations.

RESULTS

Sixty-six radiation oncologists participated (30% response rate). Median scores of most of working conditions corresponded to normal scores. Control over time management (45.8) was close to low score, while control over future (60.9) was high. Median score of job strain (48.9) was normal, whereas median score of work engagement (60) was high. Median score of burn out was low. The mean of negative work-home interactions (1.1) was higher than the mean of 0.84 in a reference sample (t=4.3; P<0.001). The most frequent problematic situations referred to work organization (e.g. time pressure) and specific resources (e.g. chief support).

CONCLUSIONS

Radiation oncologists showed a very high level of work engagement and experienced several job resources. However, some resources (as supervisor support) were missing and needed to be developed. These results were discussed in the context of motivational process described in the Job Demands-Resources Model.

A real-time safety and quality reporting system: assessment of clinical data and staff participation

PURPOSE

To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation.

METHODS AND MATERIALS

On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment).

RESULTS

During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entries in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program.

CONCLUSIONS

Incident learning systems are a useful and practical means of improving safety and quality in patient care.

Implementation of incident learning in the safety and quality management of radiotherapy: the primary experience in a new established program with advanced technology

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.