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Luximon DC, Neylon J, Ritter T, Agazaryan N, Hegde JV, Steinberg ML, Low DA, Lamb JM. Results of an Artificial Intelligence-Based Image Review System to Detect Patient Misalignment Errors in a Multi-institutional Database of Cone Beam Computed Tomography-Guided Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 120:243-252. [PMID: 38485098 DOI: 10.1016/j.ijrobp.2024.02.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/15/2024] [Accepted: 02/28/2024] [Indexed: 04/17/2024]
Abstract
PURPOSE Present knowledge of patient setup and alignment errors in image guided radiation therapy (IGRT) relies on voluntary reporting, which is thought to underestimate error frequencies. A manual retrospective patient-setup misalignment error search is infeasible owing to the bulk of cases to be reviewed. We applied a deep learning-based misalignment error detection algorithm (EDA) to perform a fully automated retrospective error search of clinical IGRT databases and determine an absolute gross patient misalignment error rate. METHODS AND MATERIALS The EDA was developed to analyze the registration between planning scans and pretreatment cone beam computed tomography scans, outputting a misalignment score ranging from 0 (most unlikely) to 1 (most likely). The algorithm was trained using simulated translational errors on a data set obtained from 680 patients treated at 2 radiation therapy clinics between 2017 and 2022. A receiver operating characteristic analysis was performed to obtain target thresholds. DICOM Query and Retrieval software was integrated with the EDA to interact with the clinical database and fully automate data retrieval and analysis during a retrospective error search from 2016 to 2017 and from 2021 to 2022 for the 2 institutions, respectively. Registrations were flagged for human review using both a hard-thresholding method and a prediction trending analysis over each individual patient's treatment course. Flagged registrations were manually reviewed and categorized as errors (>1 cm misalignment at the target) or nonerrors. RESULTS A total of 17,612 registrations were analyzed by the EDA, resulting in 7.7% flagged events. Three previously reported errors were successfully flagged by the EDA, and 4 previously unreported vertebral body misalignment errors were discovered during case reviews. False positive cases often displayed substantial image artifacts, patient rotation, and soft tissue anatomy changes. CONCLUSIONS Our results validated the clinical utility of the EDA for bulk image reviews and highlighted the reliability and safety of IGRT, with an absolute gross patient misalignment error rate of 0.04% ± 0.02% per delivered fraction.
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Affiliation(s)
- Dishane C Luximon
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California.
| | - Jack Neylon
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Timothy Ritter
- Department of Medical Physics, Virginia Commonwealth University, Richmond, Virginia
| | - Nzhde Agazaryan
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - John V Hegde
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Michael L Steinberg
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - Daniel A Low
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
| | - James M Lamb
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, California
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Kornek D, Lotter M, Szkitsak J, Dürrbeck C, Karius A, Ott OJ, Brandl C, Bert C. Improving the safety of radiotherapy treatment processes via incident-driven FMEA feedback loops. J Appl Clin Med Phys 2024:e14455. [PMID: 39101683 DOI: 10.1002/acm2.14455] [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: 03/20/2024] [Revised: 05/22/2024] [Accepted: 06/26/2024] [Indexed: 08/06/2024] Open
Abstract
BACKGROUND Failure mode and effects analysis (FMEA) is a valuable tool for radiotherapy risk assessment, yet its outputs might be unreliable due to failures not being identified or due to a lack of accurate error rates. PURPOSE A novel incident reporting system (IRS) linked to an FMEA database was tested and evaluated. The study investigated whether the system was suitable for validating a previously performed analysis and whether it could provide accurate error rates to support the expert occurrence ratings of previously identified failure modes. METHODS Twenty-three pre-identified failure modes of our external beam radiotherapy process, covering the process steps from patient admission to treatment delivery, were proffered on dedicated FMEA feedback and incident reporting terminals generated by the IRS. The clinical setting involved a computed tomography scanner, dosimetry, and five linacs. Incoming reports were used as basis to identify additional failure modes or confirm initial ones. The Kruskal-Wallis H test was applied to compare the risk priorities of the retrospective and prospective failure modes. Wald's sequential probability ratio test was used to investigate the correctness of the experts' occurrence ratings by means of the number of incoming reports. RESULTS Over a 15-month period, 304 reports were submitted. There were 0.005 (confidence interval [CI], 0.0014-0.0082) reported incidents per imaging study and 0.0006 (CI, 0.0003-0.0009) reported incidents per treatment fraction. Sixteen additional failure modes could be identified, and their risk priorities did not differ from those of the initial failure modes (p = 0.954). One failure mode occurrence rating could be increased, whereas the other 22 occurrence ratings could not be disproved. CONCLUSIONS Our approach is suitable for validating FMEAs and deducing additional failure modes on a continual basis. Accurate error rates can only be provided if a sufficient number of reports is available.
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Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Juliane Szkitsak
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christopher Dürrbeck
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Andre Karius
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Carolin Brandl
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
- Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), Erlangen, Germany
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Charters JA, Luximon D, Petragallo R, Neylon J, Low DA, Lamb JM. Automated detection of vertebral body misalignments in orthogonal kV and MV guided radiotherapy: application to a comprehensive retrospective dataset. Biomed Phys Eng Express 2024; 10:025039. [PMID: 38382110 DOI: 10.1088/2057-1976/ad2baa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 02/23/2024]
Abstract
Objective. In image-guided radiotherapy (IGRT), off-by-one vertebral body misalignments are rare but potentially catastrophic. In this study, a novel detection method for such misalignments in IGRT was investigated using densely-connected convolutional networks (DenseNets) for applications towards real-time error prevention and retrospective error auditing.Approach. A total of 4213 images acquired from 527 radiotherapy patients aligned with planar kV or MV radiographs were used to develop and test error-detection software modules. Digitally reconstructed radiographs (DRRs) and setup images were retrieved and co-registered according to the clinically applied alignment contained in the DICOM REG files. A semi-automated algorithm was developed to simulate patient positioning errors on the anterior-posterior (AP) and lateral (LAT) images shifted by one vertebral body. A DenseNet architecture was designed to classify either AP images individually or AP and LAT image pairs. Receiver-operator characteristic curves (ROC) and areas under the curves (AUC) were computed to evaluate the classifiers on test subsets. Subsequently, the algorithm was applied to the entire dataset in order to retrospectively determine the absolute off-by-one vertebral body error rate for planar radiograph guided RT at our institution from 2011-2021.Main results. The AUCs for the kV models were 0.98 for unpaired AP and 0.99 for paired AP-LAT. The AUC for the MV AP model was 0.92. For a specificity of 95%, the paired kV model achieved a sensitivity of 99%. Application of the model to the entire dataset yielded a per-fraction off-by-one vertebral body error rate of 0.044% [0.0022%, 0.21%] for paired kV IGRT including one previously unreported error.Significance. Our error detection algorithm was successful in classifying vertebral body positioning errors with sufficient accuracy for retrospective quality control and real-time error prevention. The reported positioning error rate for planar radiograph IGRT is unique in being determined independently of an error reporting system.
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Affiliation(s)
- John A Charters
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, United States of America
| | - Dishane Luximon
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, United States of America
| | - Rachel Petragallo
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, United States of America
| | - Jack Neylon
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, United States of America
| | - Daniel A Low
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, United States of America
| | - James M Lamb
- Department of Radiation Oncology, University of California, Los Angeles, CA 90095, United States of America
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Baehr A, Hummel D, Gauer T, Oertel M, Kittel C, Löser A, Todorovic M, Petersen C, Krüll A, Buchgeister M. Risk management patterns in radiation oncology-results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Strahlenther Onkol 2023; 199:350-359. [PMID: 35931889 PMCID: PMC10033570 DOI: 10.1007/s00066-022-01984-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 07/10/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Risk management (RM) is a key component of patient safety in radiation oncology (RO). We investigated current approaches on RM in German RO within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Aim was not only to evaluate a status quo of RM purposes but furthermore to discover challenges for sustainable RM that should be addressed in future research and recommendations. METHODS An online survey was conducted from June to August 2021, consisting of 18 items on prospective and reactive RM, protagonists of RM, and self-assessment concerning RM. The survey was designed using LimeSurvey and invitations were sent by e‑mail. Answers were requested once per institution. RESULTS In all, 48 completed questionnaires from university hospitals, general and non-academic hospitals, and private practices were received and considered for evaluation. Prospective and reactive RM was commonly conducted within interprofessional teams; 88% of all institutions performed prospective risk analyses. Most institutions (71%) reported incidents or near-events using multiple reporting systems. Results were presented to the team in 71% for prospective analyses and 85% for analyses of incidents. Risk conferences take place in 46% of institutions. 42% nominated a manager/committee for RM. Knowledge concerning RM was mostly rated "satisfying" (44%). However, 65% of all institutions require more information about RM by professional societies. CONCLUSION Our results revealed heterogeneous patterns of RM in RO departments, although most departments adhered to common recommendations. Identified mismatches between recommendations and implementation of RM provide baseline data for future research and support definition of teaching content.
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Affiliation(s)
- Andrea Baehr
- Outpatient Center of the UKE GmbH, Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany.
| | - Daniel Hummel
- Department of Radiotherapy and Genetics, Outpatient Center Stuttgart, University Hospital Tübingen, Stuttgart, Germany
| | - Tobias Gauer
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Oertel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Christopher Kittel
- Department of Radiation Oncology, University Hospital Münster, Münster, Germany
| | - Anastassia Löser
- Outpatient Center of the UKE GmbH, Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Manuel Todorovic
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Cordula Petersen
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Krüll
- Outpatient Center of the UKE GmbH, Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
- Department of Radiotherapy and Radiation Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Markus Buchgeister
- Faculty of Mathematics-Physics-Chemistry (II), Berliner Hochschule für Technik, Berlin, Germany
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Luximon DC, Ritter T, Fields E, Neylon J, Petragallo R, Abdulkadir Y, Charters J, Low DA, Lamb JM. Development and inter-institutional validation of an automatic vertebral-body misalignment error detector for Cone-Beam CT guided radiotherapy. Med Phys 2022; 49:6410-6423. [PMID: 35962982 DOI: 10.1002/mp.15927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/20/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In Cone-Beam Computed Tomography (CBCT) guided radiotherapy, off-by-one vertebral body misalignments are rare but serious errors which lead to wrong-site treatments. PURPOSE An automatic error detection algorithm was developed that uses a three-branch convolutional neural network error detection model (EDM) to detect off-by-one vertebral body misalignments using planning computed tomography (CT) images and setup CBCT images. METHODS Algorithm training and test data consisted of planning CTs and CBCTs from 480 patients undergoing radiotherapy treatment in the thoracic and abdominal regions at two radiotherapy clinics. The clinically applied registration was used to derive true-negative (no error) data. The setup and planning images were then misaligned by one vertebral body in both the superior and inferior directions, simulating the most likely misalignment scenarios. For each of the aligned and misaligned 3D image pairs, 2D slice pairs were automatically extracted in each anatomical plane about a point within the vertebral column. The three slice pairs obtained were then inputted to the EDM which returned a probability of vertebral misalignment. One model (EDM1 ) was trained solely on data from institution #1. EDM1 was further trained using a lower learning rate on a dataset from institution #2 to produce a fine-tuned model, EDM2 . Another model, EDM3 , was trained from scratch using a training dataset composed of data from both institutions. These three models were validated on a randomly selected and unseen dataset composed of images from both institutions, for a total of 303 image pairs. The model performances were quantified using a receiver operating characteristic analysis. Due to the rarity of vertebral body misalignments in the clinic, a minimum threshold value yielding a specificity of at least 99% was selected. Using this threshold, the sensitivity was calculated for each model, on each institution's test set separately. RESULTS When applied to the combined test set, EDM1 , EDM2 , and EDM3 resulted in an area under curve of 99.5%, 99.4% and 99.5%, respectively. EDM1 achieved a sensitivity of 96% and 88% on Institution #1 and Institution #2 test set, respectively. EDM2 obtained a sensitivity of 95% on each institution's test set. EDM3 achieved a sensitivity of 95% and 88% on Institution #1 and Institution #2 test set, respectively. CONCLUSION The proposed algorithm demonstrated accuracy in identifying off-by-one vertebral body misalignments in CBCT-guided radiotherapy that was sufficiently high to allow for practical implementation. It was found that fine-tuning the model on a multi-facility dataset can further enhance the generalizability of the algorithm. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Dishane C Luximon
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Timothy Ritter
- Department of Medical Physics, Virginia Commonwealth University, Richmond, VA, USA
| | - Emma Fields
- Department of Medical Physics, Virginia Commonwealth University, Richmond, VA, USA
| | - John Neylon
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rachel Petragallo
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Yasin Abdulkadir
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - John Charters
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Daniel A Low
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - James M Lamb
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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Simpson-Page E, Coogan P, Kron T, Lowther N, Murray R, Noble C, Smith I, Wilks R, Crowe SB. Webinar and survey on quality management principles within the Australian and New Zealand ACPSEM Workforce. Phys Eng Sci Med 2022; 45:679-685. [PMID: 35834171 DOI: 10.1007/s13246-022-01160-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Healthcare relies upon the accurate and safe delivery of patient care. This is only achievable when systems are developed to ensure high quality, robust outcomes, for instance quality management systems. The concept of quality management can take on a different meaning depending on the context in which it is found. To add complication, the amount of education required for quality management will vary depending on one's exposure to the implementation of quality systems. In part to address these issues, the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM) Queensland Branch held a quality management webinar for members and non-members across Australia and New Zealand. The purpose of the webinar was to educate and facilitate discussion regarding the application of quality management principles for the ACPSEM profession. In conjunction, a pre- and post-webinar survey was conducted to gain an insight into existing knowledge and attitudes within the professions governed by the ACPSEM and students undertaking related studies. This paper authored by the webinar speakers reintroduces the quality management principles that were discussed in webinar, exemplifies the importance of quality management skills within the ACPSEM professions and presents the results of the surveys, promoting the need for more educational resources on quality management tools.
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Affiliation(s)
- Emily Simpson-Page
- Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.
| | - Paul Coogan
- Q-TRaCE, Department of Nuclear Medicine & Specialised PET Services Queensland, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Tomas Kron
- Physical Sciences Department, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Nicholas Lowther
- Wellington Blood & Cancer Centre, Wellington Hospital, Wellington, New Zealand
| | - Rebecca Murray
- Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, Australia
| | - Christopher Noble
- Department of Radiation Oncology, Princess Alexandra Hospital, Brisbane, Australia
| | - Ian Smith
- St. Andrews War Memorial Hospital, Brisbane, Australia
| | - Rachael Wilks
- Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, Australia.,School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Australia
| | - Scott B Crowe
- Cancer Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Herston Biofabrication Institute, Metro North Hospital and Health Service, Brisbane, Australia.,School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, Australia.,School of Chemistry and Physics, Queensland University of Technology, Brisbane, Australia
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Adamson L, Beldham‐Collins R, Sykes J, Thwaites D. Evaluating incident learning systems and safety culture in two radiation oncology departments. J Med Radiat Sci 2022; 69:208-217. [PMID: 34882982 PMCID: PMC9163481 DOI: 10.1002/jmrs.563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/15/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC. METHODS A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs. RESULTS Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no-blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS. CONCLUSION An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.
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Affiliation(s)
- Laura Adamson
- Department of Radiation OncologyCrown Princess Mary Cancer CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyBlacktown Cancer & Haematology CentreSydneyNew South WalesAustralia
- School of Physics, Institute of Medical PhysicsUniversity of SydneySydneyNew South WalesAustralia
| | - Rachael Beldham‐Collins
- Department of Radiation OncologyCrown Princess Mary Cancer CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyBlacktown Cancer & Haematology CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyNepean Hospital Cancer Care CentreSydneyNew South WalesAustralia
| | - Jonathan Sykes
- Department of Radiation OncologyCrown Princess Mary Cancer CentreSydneyNew South WalesAustralia
- Department of Radiation OncologyBlacktown Cancer & Haematology CentreSydneyNew South WalesAustralia
- School of Physics, Institute of Medical PhysicsUniversity of SydneySydneyNew South WalesAustralia
| | - David Thwaites
- School of Physics, Institute of Medical PhysicsUniversity of SydneySydneyNew South WalesAustralia
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Le Cornu E, Murray S, Brown E, Bernard A, Shih F, Ferrari‐Anderson J, Jenkins M. Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen-year period. J Med Radiat Sci 2021; 68:356-363. [PMID: 34053193 PMCID: PMC8655886 DOI: 10.1002/jmrs.517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/01/2021] [Accepted: 05/08/2021] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Emma Le Cornu
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Shillayne Murray
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Elizabeth Brown
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | - Anne Bernard
- QCIF Facility for Advanced Bioinformatics, Institute for Molecular BioscienceThe University of QueenslandSt LuciaQueenslandAustralia
| | - Feng‐Jung Shih
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
| | | | - Michael Jenkins
- Radiation OncologyPrincess Alexandra HospitalBrisbaneQueenslandAustralia
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Oelofse I, van Staden J, Coetzee N, Steyn J. Quality management in radiotherapy: A 9-year review of incident reporting within a multifacility organisation. SOUTH AFRICAN JOURNAL OF ONCOLOGY 2021. [DOI: 10.4102/sajo.v5i0.170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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