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He H, Peng X, Luo D, Wei W, Li J, Wang Q, Xiao Q, Li G, Bai S. Causal analysis of radiotherapy safety incidents based on a hybrid model of HFACS and Bayesian network. Front Public Health 2024; 12:1351367. [PMID: 38873320 PMCID: PMC11169683 DOI: 10.3389/fpubh.2024.1351367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
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.
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Affiliation(s)
- Haiping He
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Xudong Peng
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Dashuang Luo
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Weige Wei
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Jing Li
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Qiang Wang
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Qing Xiao
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Guangjun Li
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
| | - Sen Bai
- Department of Radiation Oncology, Cancer Center, West China Hospital, Sichuan University, Chengdu, China
- Department of Radiotherapy Physics & Technology, West China Hospital, Sichuan University, Chengdu, China
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Zarei M, Gershan V, Holmberg O. Safety in radiation oncology (SAFRON): Learning about incident causes and safety barriers in external beam radiotherapy. Phys Med 2023; 111:102618. [PMID: 37311337 DOI: 10.1016/j.ejmp.2023.102618] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/02/2023] [Accepted: 06/02/2023] [Indexed: 06/15/2023] Open
Abstract
PURPOSE Safety in Radiation Oncology (SAFRON) is a reporting and learning system on radiotherapy and radionuclide therapy incidents and near misses. The primary aim of this paper is to examine whether any discernible patterns exist in the causes of reported incidents and safety barriers within the SAFRON system concerning external beam radiotherapy. METHODS AND MATERIALS This study focuses on external beam radiotherapy incidents, reviewing 1685 reports since the inception of SAFRON until December 2021. Reports that did not identify causes of incidents and safety barriers were excluded from the final study population. RESULTS Simple two-dimensional radiotherapy or electron beam therapy were represented by 97 reports, three-dimensional conformal radiotherapy by 39 reports, modulated arc therapy by 12 reports, intensity modulated radiation therapy by 11 reports, stereotactic radiosurgery by 4 reports, and radiotherapy with protons or other particles by 1 report, while for 92 of them, no information on treatment method had been provided. Most of the reported incidents were minor incidents and were discovered by the radiation therapist. Inadequate direction/information in staff communication was the most frequently reported cause of incident, and regular independent chart check was the most common safety barrier. CONCLUSIONS The results indicate that the majority of incidents were reported by radiation therapists, and the majority of these incidents were classified as minor. Communication problems and failure to follow standards/procedures/practices were the most frequent causes of incidents. Furthermore, regular independent chart checking was the most frequently identified safety barrier.
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Affiliation(s)
- Maryam Zarei
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria.
| | - Vesna Gershan
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria
| | - Ola Holmberg
- Radiation Protection of Patients Unit, Radiation Safety and Monitoring Section, Division of Radiation, Transport and Waste Safety, International Atomic Energy Agency, Vienna, Austria
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Yu N, Magnelli A, LaHurd D, Mastroianni A, Murray E, Close M, Hugebeck B, Suh JH, Xia P. Using a daily monitoring system to reduce treatment position override rates in external beam radiation therapy. J Appl Clin Med Phys 2022; 23:e13629. [PMID: 35506575 PMCID: PMC9278683 DOI: 10.1002/acm2.13629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/30/2022] [Accepted: 04/15/2022] [Indexed: 11/09/2022] Open
Abstract
PURPOSE/OBJECTIVES To report our 7-year experience with a daily monitoring system to significantly reduce couch position overrides and errors in patient treatment positioning. MATERIALS AND METHODS Treatment couch position override data were extracted from a radiation oncology-specific electronic medical record system from 2012 to 2018. During this period, we took several actions to reduce couch position overrides, including reducing the number of tolerance tables from 18 to 6, tightening tolerance limits, enforcing time outs, documenting reasons for overrides, and timely reviewing of overrides made from previous treatment day. The tolerance tables included treatment categories for head and neck (HN) (with/without cone beam CT [CBCT]), body (with/without CBCT), stereotactic body radiotherapy (SBRT), and clinical setup for electron beams. For the same time period, we also reported treatment positioning-related incidents that were recorded in our departmental incident report system. To verify our tolerance limits, we further examined couch shifts after daily kilovoltage CBCT (kV-CBCT) for the patients treated from 2018 to 2021. RESULTS From 2012 to 2018, the override rate decreased from 11.2% to 1.6%/year, whereas the number of fractions treated in the department increased by 23%. The annual patient positioning error rate was also reduced from 0.019% in 2012, to 0.004% in 2017 and 0% in 2018. For patients treated under daily kV-CBCT guidance from 2018 to 2021, the applied couch shifts after imaging registration that exceeded the tolerance limits were low, <1% for HN, <1.2% for body, and <2.6% for SBRT. CONCLUSIONS The daily monitoring system, which enables a timely review of overrides, significantly reduced the number of treatment couch position overrides and ultimately resulted in a decrease in treatment positioning errors. For patients treated with daily kV-CBCT guidance, couch position shifts after CBCT image guidance demonstrated a low rate of exceeding the set tolerance.
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Affiliation(s)
- Naichang Yu
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony Magnelli
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Danielle LaHurd
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anthony Mastroianni
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric Murray
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mike Close
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Hugebeck
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John H Suh
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ping Xia
- Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Medical physics external beam plan review: What contributes to the variability? Phys Med 2021; 89:293-302. [PMID: 34488178 DOI: 10.1016/j.ejmp.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE In this article we report on the results of a survey of physics plan review practices conducted by the Cancer Care Ontario Communities of Practice and the variations in practice between and within centers. METHODS The medical physicists at each center worked together to complete the survey and submit a single response for that center. A 4-point Likert scale, used to report the variation in practice at each center, was quantified into two parameters: "Intra-center variation", the distribution of responses within the center, and "Variation between centers", the difference between the center's response and the provincial mean. These metrics were correlated with center characteristics to identify factors that impacted on variations in practice. RESULTS Bolus and heterogeneity correction were the only two items checked by all physicists in all centers. In more than half of the centers, image registration and DVH binning are not likely checked by physics. A significant difference in the variation between centers is observed for centers that used a single vendor's products. Centers that used an official checklist indicated higher levels and a wider range of Intra-center variation. Higher workload did not affect the variation in checking patterns between physicists in the same center. CONCLUSIONS The effect of a center's resources on their checking practice suggest that local environment and workflow be accounted for when implementing TG275 guidelines. The observation that standardized checklists did not reduce checking variability point to the importance of following the checklist development guidelines in MPPG4 to avoid ineffective checklists.
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The role of surface-guided radiation therapy for improving patient safety. Radiother Oncol 2021; 163:229-236. [PMID: 34453955 DOI: 10.1016/j.radonc.2021.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/27/2021] [Accepted: 08/11/2021] [Indexed: 11/20/2022]
Abstract
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.
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Kisling K, Cardenas C, Anderson BM, Zhang L, Jhingran A, Simonds H, Balter P, Howell RM, Schmeler K, Beadle BM, Court L. Automatic Verification of Beam Apertures for Cervical Cancer Radiation Therapy. Pract Radiat Oncol 2020; 10:e415-e424. [PMID: 32450365 PMCID: PMC8133770 DOI: 10.1016/j.prro.2020.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 03/16/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Automated tools can help identify radiation treatment plans of unacceptable quality. To this end, we developed a quality verification technique to automatically verify the clinical acceptability of beam apertures for 4-field box treatments of patients with cervical cancer. By comparing the beam apertures to be used for treatment with a secondary set of beam apertures developed automatically, this quality verification technique can flag beam apertures that may need to be edited to be acceptable for treatment. METHODS AND MATERIALS The automated methodology for creating verification beam apertures uses a deep learning model trained on beam apertures and digitally reconstructed radiographs from 255 clinically acceptable planned treatments (as rated by physicians). These verification apertures were then compared with the treatment apertures using spatial comparison metrics to detect unacceptable treatment apertures. We tested the quality verification technique on beam apertures from 80 treatment plans. Each plan was rated by physicians, where 57 were rated clinically acceptable and 23 were rated clinically unacceptable. RESULTS Using various comparison metrics (the mean surface distance, Hausdorff distance, and Dice similarity coefficient) for the 2 sets of beam apertures, we found that treatment beam apertures rated acceptable had significantly better agreement with the verification beam apertures than those rated unacceptable (P < .01). Upon receiver operating characteristic analysis, we found the area under the curve for all metrics to be 0.89 to 0.95, which demonstrated the high sensitivity and specificity of our quality verification technique. CONCLUSIONS We found that our technique of automatically verifying the beam aperture is an effective tool for flagging potentially unacceptable beam apertures during the treatment plan review process. Accordingly, we will clinically deploy this quality verification technique as part of a fully automated treatment planning tool and automated plan quality assurance program.
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Affiliation(s)
- Kelly Kisling
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Carlos Cardenas
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Brian M Anderson
- Department of Imaging Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Lifei Zhang
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Anuja Jhingran
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Hannah Simonds
- Division of Radiation Oncology, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Peter Balter
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rebecca M Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Kathleen Schmeler
- Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Beth M Beadle
- Department of Radiation Oncology - Radiation Therapy, Stanford University, Stanford, California
| | - Laurence Court
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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Ford E, Conroy L, Dong L, de Los Santos LF, Greener A, Gwe-Ya Kim G, Johnson J, Johnson P, Mechalakos JG, Napolitano B, Parker S, Schofield D, Smith K, Yorke E, Wells M. Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275. Med Phys 2020; 47:e236-e272. [PMID: 31967655 DOI: 10.1002/mp.14030] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND While the review of radiotherapy treatment plans and charts by a medical physicist is a key component of safe, high-quality care, very few specific recommendations currently exist for this task. AIMS The goal of TG-275 is to provide practical, evidence-based recommendations on physics plan and chart review for radiation therapy. While this report is aimed mainly at medical physicists, others may benefit including dosimetrists, radiation therapists, physicians and other professionals interested in quality management. METHODS The scope of the report includes photon/electron external beam radiotherapy (EBRT), proton radiotherapy, as well as high-dose rate (HDR) brachytherapy for gynecological applications (currently the highest volume brachytherapy service in most practices). The following review time points are considered: initial review prior to treatment, weekly review, and end-of-treatment review. The Task Group takes a risk-informed approach to developing recommendations. A failure mode and effects analysis was performed to determine the highest-risk aspects of each process. In the case of photon/electron EBRT, a survey of all American Association of Physicists in Medicine (AAPM) members was also conducted to determine current practices. A draft of this report was provided to the full AAPM membership for comment through a 3-week open-comment period, and the report was revised in response to these comments. RESULTS The highest-risk failure modes included 112 failure modes in photon/electron EBRT initial review, 55 in weekly and end-of-treatment review, 24 for initial review specific to proton therapy, and 48 in HDR brachytherapy. A 103-question survey on current practices was released to all AAPM members who self-reported as working in the radiation oncology field. The response rate was 33%. The survey data and risk data were used to inform recommendations. DISCUSSION Tables of recommended checks are presented and recommendations for best practice are discussed. Suggestions to software vendors are also provided. CONCLUSIONS TG-275 provides specific recommendations for physics plan and chart review which should enhance the safety and quality of care for patients receiving radiation treatments.
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Affiliation(s)
- Eric Ford
- University of Washington Medical Center, Seattle, WA, USA
| | - Leigh Conroy
- The Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Lei Dong
- University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | | | | | | | | | | | | - Koren Smith
- Mary Bird Perkin Cancer Center, Baton Rouge, LA, USA
| | - Ellen Yorke
- Memorial Sloan-Kettering Cancer Center, Manhattan, NY, USA
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Yamamoto T, Oka K. [A Human Factors Study Using VTA for Incident Cases in Radiotherapy]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2019; 75:1249-1259. [PMID: 31748450 DOI: 10.6009/jjrt.2019_jsrt_75.11.1249] [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: 11/11/2022]
Abstract
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.
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Affiliation(s)
- Toshijiro Yamamoto
- Department of Radiation Oncology, Osaka Noe Saiseikai Hospital.,Graduate School of Health Care Sciences, Jikei Institute
| | - Kohei Oka
- Graduate School of Health Care Sciences, Jikei Institute
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Patterns of Incident Reporting Across Clinical Sites in a Regionally Expanding Academic Radiation Oncology Department. J Am Coll Radiol 2019; 16:915-921. [DOI: 10.1016/j.jacr.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/26/2018] [Accepted: 12/05/2018] [Indexed: 11/21/2022]
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Adoption of an incident learning system in a regionally expanding academic radiation oncology department. Rep Pract Oncol Radiother 2019; 24:338-343. [PMID: 31194042 DOI: 10.1016/j.rpor.2019.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 02/28/2019] [Accepted: 05/18/2019] [Indexed: 11/24/2022] Open
Abstract
Aim and Background We describe a successful implementation of a departmental incident learning system (ILS) across a regionally expanding academic radiation oncology department, dovetailing with a structured integration of the safety and quality program across clinical sites. Materials and methods m Over 6 years between 2011 and 2017, a long-standing departmental ILS was deployed to 4 clinical locations beyond the primary clinical location where it had been established. We queried all events reported to the ILS during this period and analyzed trends in reporting by clinical site. The chi-square test was used to determine whether differences over time in the rate of reporting were statistically significant. We describe a synchronous development of a common safety and quality program over the same period. Results There was an overall increase in the number of event reports from each location over the time period from 2011 to 2017. The percentage increase in reported events from the first year of implementation to 2017 was 457% in site 1, 166.7% in site 2, 194.3% in site 3, 1025% in site 4, and 633.3% in site 5, with an overall increase of 677.7%. A statistically significant increase in the rate of reporting was seen from the first year of implementation to 2017 (p < 0.001 for all sites). Conclusions We observed significant increases in event reporting over a 6-year period across 5 regional sites within a large academic radiation oncology department, during which time we expanded and enhanced our safety and quality program, including regional integration. Implementing an ILS and structuring a safety and quality program together result in the successful integration of the ILS into existing departmental infrastructure.
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Gopan O, Smith WP, Chvetsov A, Hendrickson K, Kalet A, Kim M, Nyflot M, Phillips M, Young L, Novak A, Zeng J, Ford E. Utilizing simulated errors in radiotherapy plans to quantify the effectiveness of the physics plan review. Med Phys 2018; 45:5359-5365. [DOI: 10.1002/mp.13242] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 09/27/2018] [Accepted: 09/27/2018] [Indexed: 12/18/2022] Open
Affiliation(s)
- Olga Gopan
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Wade P. Smith
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Alexei Chvetsov
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Kristi Hendrickson
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Alan Kalet
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Minsun Kim
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Matthew Nyflot
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Mark Phillips
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Lori Young
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Avrey Novak
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Jing Zeng
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
| | - Eric Ford
- Department of Radiation Oncology University of Washington Medical Center 1959 NE Pacific Street, Box 356043 Seattle Washington 98195 USA
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Real-time management of incident learning reports in a radiation oncology department. Pract Radiat Oncol 2018; 8:e337-e345. [DOI: 10.1016/j.prro.2018.04.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 04/08/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022]
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13
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Greenham S, Manley S, Turnbull K, Hoffmann M, Fonseca A, Westhuyzen J, Last A, Aherne NJ, Shakespeare TP. Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres. Rep Pract Oncol Radiother 2018; 23:220-227. [PMID: 29760597 PMCID: PMC5948319 DOI: 10.1016/j.rpor.2018.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/05/2018] [Accepted: 04/08/2018] [Indexed: 10/16/2022] Open
Abstract
AIM To develop and apply a clinical incident taxonomy for radiation therapy. BACKGROUND Capturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability. METHODS AND MATERIALS A clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care. The taxonomy was applied to all clinical incidents occurring at three integrated cancer centres for the years 2011-2015. Incidents were managed locally, audited and feedback disseminated to all centres. RESULTS Across the five years the total incident rate (per 100 courses) was 8.54; the radiotherapy-specific coded rate was 6.71. The rate of true adverse events (unintended treatment and potential patient harm) was 1.06. Adverse events, where no harm was identified, occurred at a rate of 2.76 per 100 courses. Despite workload increases, overall and actual rates both exhibited downward trends over the 5-year period. The taxonomy captured previously unidentified quality assurance failures; centre-specific issues that contributed to variations in incident trends were also identified. CONCLUSIONS The application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.
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Affiliation(s)
- Stuart Greenham
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Stephen Manley
- Department of Radiation Oncology, Northern New South Wales Cancer Institute, Lismore, New South Wales, Australia
| | - Kirsty Turnbull
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Matthew Hoffmann
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Amara Fonseca
- Department of Radiation Oncology, Northern New South Wales Cancer Institute, Lismore, New South Wales, Australia
| | - Justin Westhuyzen
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
| | - Andrew Last
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Port Macquarie, New South Wales, Australia
| | - Noel J. Aherne
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
| | - Thomas P. Shakespeare
- Department of Radiation Oncology, Mid-North Coast Cancer Institute, Coffs Harbour, New South Wales, Australia
- Faculty of Medicine, University of New South Wales, New South Wales, Australia
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A multi-institutional study of secondary check of treatment planning using Clarkson-based dose calculation for three-dimensional radiotherapy. Phys Med 2018; 49:19-27. [DOI: 10.1016/j.ejmp.2018.04.394] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/24/2022] Open
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15
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Ford EC, Evans SB. Incident learning in radiation oncology: A review. Med Phys 2018; 45:e100-e119. [PMID: 29419944 DOI: 10.1002/mp.12800] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 12/17/2017] [Accepted: 01/03/2018] [Indexed: 11/06/2022] Open
Abstract
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.
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Affiliation(s)
- Eric C Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA, 98195, USA
| | - Suzanne B Evans
- Department of Radiation Oncology, Yale University, New Haven, CT, 06510, USA
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16
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Snyder C, Pogue BW, Jermyn M, Tendler I, Andreozzi JM, Bruza P, Krishnaswamy V, Gladstone DJ, Jarvis LA. Algorithm development for intrafraction radiotherapy beam edge verification from Cherenkov imaging. J Med Imaging (Bellingham) 2018; 5:015001. [PMID: 29322071 DOI: 10.1117/1.jmi.5.1.015001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Accepted: 12/05/2017] [Indexed: 11/14/2022] Open
Abstract
Imaging of Cherenkov light emission from patient tissue during fractionated radiotherapy has been shown to be a possible way to visualize beam delivery in real time. If this tool is advanced as a delivery verification methodology, then a sequence of image processing steps must be established to maximize accurate recovery of beam edges. This was analyzed and developed here, focusing on the noise characteristics and representative images from both phantoms and patients undergoing whole breast radiotherapy. The processing included temporally integrating video data into a single, composite summary image at each control point. Each image stack was also median filtered for denoising and ultimately thresholded into a binary image, and morphologic small hole removal was used. These processed images were used for day-to-day comparison computation, and either the Dice coefficient or the mean distance to conformity values can be used to analyze them. Systematic position shifts of the phantom up to 5 mm approached the observed variation values of the patient data. This processing algorithm can be used to analyze the variations seen in patients being treated concurrently with daily Cherenkov imaging to quantify the day-to-day disparities in delivery as a quality audit system for position/beam verification.
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Affiliation(s)
- Clare Snyder
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Brian W Pogue
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States.,DoseOptics LLC, Lebanon, New Hampshire, United States.,Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, Lebanon, New Hampshire, United States
| | - Michael Jermyn
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States.,DoseOptics LLC, Lebanon, New Hampshire, United States
| | - Irwin Tendler
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | | | - Petr Bruza
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States
| | - Venkat Krishnaswamy
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States.,DoseOptics LLC, Lebanon, New Hampshire, United States
| | - David J Gladstone
- Dartmouth College, Thayer School of Engineering, Hanover, New Hampshire, United States.,Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, Lebanon, New Hampshire, United States.,Geisel School of Medicine, Department of Medicine, Hanover, New Hampshire, United States
| | - Lesley A Jarvis
- Dartmouth-Hitchcock Medical Center, Norris Cotton Cancer Center, Lebanon, New Hampshire, United States.,Geisel School of Medicine, Department of Medicine, Hanover, New Hampshire, United States
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17
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Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy. Pract Radiat Oncol 2017; 7:346-353. [DOI: 10.1016/j.prro.2017.05.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/08/2017] [Accepted: 05/11/2017] [Indexed: 11/21/2022]
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18
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Abstract
Although many error pathways are common to both stereotactic body radiation therapy (SBRT) and conventional radiation therapy, SBRT presents a special set of challenges including short treatment courses and high-doses, an enhanced reliance on imaging, technical challenges associated with commissioning, special resource requirements for staff and training, and workflow differences. Emerging data also suggest that errors occur at a higher rate in SBRT treatments. Furthermore, when errors do occur they often have a greater effect on SBRT treatments. Given these challenges, it is important to understand and employ systematic approaches to ensure the quality and safety of SBRT treatment. Here, we outline the pathways by which error can occur in SBRT, illustrated through a series of case studies, and highlight 9 specific well-established tools to either reduce error or minimize its effect to the patient or both.
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Affiliation(s)
- Eric Ford
- Department of Radiation Oncology, University of Washington, Seattle, WA.
| | - Sonja Dieterich
- Department of Radiation Oncology, University of California, Davis, CA
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Gopan O, Zeng J, Novak A, Nyflot M, Ford E. The effectiveness of pretreatment physics plan review for detecting errors in radiation therapy. Med Phys 2016; 43:5181. [DOI: 10.1118/1.4961010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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