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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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Shen J, Chen M, Qiu H, Yang C, Liu H, Chen J, Wang D, Zhao H, Sun S, Mei Z, Xie C, Wang X. Evaluation and improvement of the safety of 3D-printed template assisted intracavitary/interstitial brachytherapy for cervical cancer using repeat FMEA. Brachytherapy 2024; 23:580-589. [PMID: 38960768 DOI: 10.1016/j.brachy.2024.05.003] [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: 08/21/2023] [Revised: 02/07/2024] [Accepted: 05/09/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND AND PURPOSE 3D-printed templates are used in intracavitary/interstitial brachytherapy (3DP-IC/IS) for locally advanced cervical cancer (LACC). We applied failure mode and effects analysis (FMEA) twice in one year to improve 3DP-IC/IS safety. MATERIALS AND METHODS A risk assessment group was established. We created a process map for 3DP-IC/IS procedures, identifying potential failure modes (FMs) and evaluating occurrence (O), detectability (D), severity (S), and risk priority number (RPN = O*D*S). High RPN values identified high-risk FMs, and quality control (QC) methods were determined by root cause analysis. A second FMEA was performed a year later. RESULTS The 3DP-IC/IS process included 10 main steps, 48 subprocesses, and 54 FMs. Initial RPN values ranged from 4.50 to 171.00 (median 50.50; average 52.18). Ten high-risk FMs were identified: (1) unreasonable needle track design (171.00/85.50), (2) noncoplanar needle label identification failure (126.00/64.00), (3) template model reconstruction failure (121.50/62.50), (4) improper gauze filling (112.00/60.25), (5) poor needle position (112.00/52.50). QC interventions lowered all high-risk RPN values during the second assessment. CONCLUSIONS A feasible 3DP-IC/IS process was proposed. Staff training, automatic needle path planning, insertion guidance diagrams, template checking, system commissioning, and template design improvements effectively enhanced process safety.
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Affiliation(s)
- Jiuling Shen
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Min Chen
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hui Qiu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Chunxu Yang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hui Liu
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ji Chen
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Dajiang Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hongli Zhao
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Shaoxing Sun
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Zijie Mei
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Conghua Xie
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xiaoyong Wang
- Department of Radiation and Medical Oncology, Hubei Key Laboratory of Tumor Biological Behaviors, Hubei Cancer Clinical Study Center, Zhongnan Hospital of Wuhan University, Wuhan, China..
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Hobbis D, Armstrong MD, Patel SH, Tegtmeier RC, Laughlin BS, Chitsazzadeh S, Clouser EL, Smetanick JL, Pettit J, Gagneur JD, Stoker JB, Rong Y, Buckey CR. Comprehensive clinical implementation, workflow, and FMEA of bespoke silicone bolus cast from 3D printed molds using open-source resources. J Appl Clin Med Phys 2024:e14498. [PMID: 39189817 DOI: 10.1002/acm2.14498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/09/2024] [Accepted: 07/12/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Bolus materials have been used for decades in radiotherapy. Most frequently, these materials are utilized to bring dose closer to the skin surface to cover superficial targets optimally. While cavity filling, such as nasal cavities, is desirable, traditional commercial bolus is lacking, requiring other solutions. Recently, investigators have worked on utilizing 3D printing technology, including commercially available solutions, which can overcome some challenges with traditional bolus. PURPOSE To utilize failure modes and effects analysis (FMEA) to successfully implement a comprehensive 3D printed bolus solution to replace commercial bolus in our clinic using a series of open-source (or free) software products. METHODS 3D printed molds for bespoke bolus were created by exporting the DICOM structures of the bolus designed in the treatment planning system and manipulated to create a multipart mold for 3D printing. A silicone (Ecoflex 00-30) mixture is poured into the mold and cured to form the bolus. Molds for sheet bolus of five thicknesses were also created. A comprehensive FMEA was performed to guide workflow adjustments and QA steps. RESULTS The process map identified 39 and 30 distinct steps for the bespoke and flat sheet bolus workflows, respectively. The corresponding FMEA highlighted 119 and 86 failure modes, with 69 shared between the processes. Misunderstanding of plan intent was a potential cause for most of the highest-scoring failure modes, indicating that physics and dosimetry involvement early in the process is paramount. CONCLUSION FMEA informed the design and implementation of QA steps to guarantee a safe and high-quality comprehensive implementation of silicone bolus from 3D printed molds. This approach allows for greater adaptability not afforded by traditional bolus, as well as potential dissemination to other clinics due to the open-source nature of the workflow.
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Affiliation(s)
- Dean Hobbis
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
- Department of Radiation Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri, USA
| | - Michael D Armstrong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Samir H Patel
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Riley C Tegtmeier
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
- University of South Florida Morsani College of Medicine and Tampa General Hospital Cancer Institute
| | - Brady S Laughlin
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Shadi Chitsazzadeh
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Edward L Clouser
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Justin Pettit
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Justin D Gagneur
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Joshua B Stoker
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Yi Rong
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Courtney R Buckey
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
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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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Rippke C, Renkamp CK, Stahl-Arnsberger C, Miltner A, Buchele C, Hörner-Rieber J, Ristau J, Debus J, Alber M, Klüter S. A body mass index-based method for "MR-only" abdominal MR-guided adaptive radiotherapy. Z Med Phys 2024; 34:456-467. [PMID: 36759229 DOI: 10.1016/j.zemedi.2022.12.001] [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: 08/09/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 02/10/2023]
Abstract
PURPOSE Dose calculation for MR-guided radiotherapy (MRgRT) at the 0.35 T MR-Linac is currently based on deformation of planning CTs (defCT) acquired for each patient. We present a simple and robust bulk density overwrite synthetic CT (sCT) method for abdominal treatments in order to streamline clinical workflows. METHOD Fifty-six abdominal patient treatment plans were retrospectively evaluated. All patients had been treated at the MR-Linac using MR datasets for treatment planning and plan adaption and defCT for dose calculation. Bulk density CTs (4M-sCT) were generated from MR images with four material compartments (bone, lung, air, soft tissue). The relative electron densities (RED) for bone and lung were extracted from contoured CT structure average REDs. For soft tissue, a correlation between BMI and RED was evaluated. Dose was recalculated on 4M-sCT and compared to dose distributions on defCTs assessing dose differences in the PTV and organs at risk (OAR). RESULTS Mean RED of bone was 1.17 ± 0.02, mean RED of lung 0.17 ± 0.05. The correlation between BMI and RED for soft tissue was statistically significant (p < 0.01). PTV dose differences between 4M-sCT and defCT were Dmean: -0.4 ± 1.0%, D1%: -0.3 ± 1.1% and D95%: -0.5 ± 1.0%. OARs showed D2%: -0.3 ± 1.9% and Dmean: -0.1 ± 1.4% differences. Local 3D gamma index pass rates (2%/2mm) between dose calculated using 4M-sCT and defCT were 96.8 ± 2.6% (range 89.9-99.6%). CONCLUSION The presented method for sCT generation enables precise dose calculation for MR-only abdominal MRgRT.
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Affiliation(s)
- Carolin Rippke
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany; Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany.
| | - C Katharina Renkamp
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany
| | - Christiane Stahl-Arnsberger
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Annette Miltner
- Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany
| | - Carolin Buchele
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany; Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany; Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany; German Cancer Consortium (DKTK), Core-center Heidelberg, Heidelberg, Germany
| | - Jonas Ristau
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany; Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany; Clinical Cooperation Unit Radiation Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 280, 69120 Heidelberg, Germany; National Center for Tumor Diseases (NCT), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany; Heidelberg Ion-Beam Therapy Center (HIT), Im Neuenheimer Feld 450, 69120 Heidelberg, Germany; German Cancer Consortium (DKTK), Core-center Heidelberg, Heidelberg, Germany
| | - Markus Alber
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany; Medical Faculty, University of Heidelberg, Im Neuenheimer Feld 672, 69120 Heidelberg, Germany
| | - Sebastian Klüter
- Department of Radiation Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; Heidelberg Institute of Radiation Oncology (HIRO), National Center for Radiation Oncology (NCRO), Heidelberg, Germany.
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Kornek D, Menichelli D, Leske J, Hofmann M, Antkiewicz D, Brandt T, Ott OJ, Lotter M, Lang-Welzenbach M, Fietkau R, Bert C. Development and clinical implementation of a digital system for risk assessments for radiation therapy. Z Med Phys 2024; 34:371-383. [PMID: 37666699 DOI: 10.1016/j.zemedi.2023.08.003] [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: 02/15/2023] [Revised: 08/08/2023] [Accepted: 08/09/2023] [Indexed: 09/06/2023]
Abstract
Before introducing new treatment techniques, an investigation of hazards due to unintentional radiation exposures is a reasonable activity for proactively increasing patient safety. As dedicated software is scarce, we developed a tool for risk assessment to design a quality management program based on best practice methods, i.e., process mapping, failure modes and effects analysis and fault tree analysis. Implemented as a web database application, a single dataset was used to describe the treatment process and its failure modes. The design of the system and dataset allowed failure modes to be represented both visually as fault trees and in a tabular form. Following the commissioning of the software for our department, previously conducted risk assessments were migrated to the new system after being fully re-assessed which revealed a shift in risk priorities. Furthermore, a weighting factor was investigated to bring risk levels of the migrated assessments into perspective. The compensation did not affect high priorities but did re-prioritize in the midrange of the ranking. We conclude that the tool is suitable to conduct multiple risk assessments and concomitantly keep track of the overall quality management activities.
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Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | | | - Jörg Leske
- IBA Dosimetry GmbH, 90592 Schwarzenbruck, Germany.
| | | | | | - Tobias Brandt
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Oliver J Ott
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Michael Lotter
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Marga Lang-Welzenbach
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Rainer Fietkau
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
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Behzadipour M, Palta J, Ma T, Yuan L, Kim S, Kirby S, Torkelson L, Baker J, Koenig T, Khalifa MA, Hawranko R, Richeson D, Fields E, Weiss E, Song WY. Optimization of treatment workflow for 0.35T MR-Linac system. J Appl Clin Med Phys 2024; 25:e14393. [PMID: 38742819 PMCID: PMC11302807 DOI: 10.1002/acm2.14393] [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: 12/06/2023] [Revised: 03/15/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE This study presents a novel and comprehensive framework for evaluating magnetic resonance guided radiotherapy (MRgRT) workflow by integrating the Failure Modes and Effects Analysis (FMEA) approach with Time-Driven Activity-Based Costing (TDABC). We assess the workflow for safety, quality, and economic implications, providing a holistic understanding of the MRgRT implementation. The aim is to offer valuable insights to healthcare practitioners and administrators, facilitating informed decision-making regarding the 0.35T MRIdian MR-Linac system's clinical workflow. METHODS For FMEA, a multidisciplinary team followed the TG-100 methodology to assess the MRgRT workflow's potential failure modes. Following the mitigation of primary failure modes and workflow optimization, a treatment process was established for TDABC analysis. The TDABC was applied to both MRgRT and computed tomography guided RT (CTgRT) for typical five-fraction stereotactic body RT (SBRT) treatments, assessing total workflow and costs associated between the two treatment workflows. RESULTS A total of 279 failure modes were identified, with 31 categorized as high-risk, 55 as medium-risk, and the rest as low-risk. The top 20% risk priority numbers (RPN) were determined for each radiation oncology care team member. Total MRgRT and CTgRT costs were assessed. Implementing technological advancements, such as real-time multi leaf collimator (MLC) tracking with volumetric modulated arc therapy (VMAT), auto-segmentation, and increasing the Linac dose rate, led to significant cost savings for MRgRT. CONCLUSION In this study, we integrated FMEA with TDABC to comprehensively evaluate the workflow and the associated costs of MRgRT compared to conventional CTgRT for five-fraction SBRT treatments. FMEA analysis identified critical failure modes, offering insights to enhance patient safety. TDABC analysis revealed that while MRgRT provides unique advantages, it may involve higher costs. Our findings underscore the importance of exploring cost-effective strategies and key technological advancements to ensure the widespread adoption and financial sustainability of MRgRT in clinical practice.
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Affiliation(s)
- Mojtaba Behzadipour
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Jatinder Palta
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Tianjun Ma
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lulin Yuan
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Siyong Kim
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Suzanne Kirby
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Laurel Torkelson
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - James Baker
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Tammy Koenig
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Mateb Al Khalifa
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Robert Hawranko
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Dylan Richeson
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Emma Fields
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Elisabeth Weiss
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - William Y. Song
- Department of Radiation OncologyVirginia Commonwealth UniversityRichmondVirginiaUSA
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Kornek D, Bert C. Process failure mode and effects analysis for external beam radiotherapy: Introducing a literature-based template and a novel action priority. Z Med Phys 2024; 34:358-370. [PMID: 38429170 DOI: 10.1016/j.zemedi.2024.02.002] [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: 11/10/2023] [Revised: 01/21/2024] [Accepted: 02/07/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The first aim of the study was to create a general template for analyzing potential failures in external beam radiotherapy, EBRT, using the process failure mode and effects analysis (PFMEA). The second aim was to modify the action priority (AP), a novel prioritization method originally introduced by the Automotive Industry Action Group (AIAG), to work with different severity, occurrence, and detection rating systems used in radiation oncology. METHODS AND MATERIALS The AIAG PFMEA approach was employed in combination with an extensive literature survey to develop the EBRT-PFMEA template. Subsets of high-risk failure modes found through the literature survey were added to the template where applicable. Our modified AP for radiation oncology (RO AP) was defined using a weighted sum of severity, occurrence, and detectability. Then, Monte Carlo simulations were conducted to compare the original AIAG AP, the RO AP, and the risk priority number (RPN). The results of the simulations were used to determine the number of additional corrective actions per failure mode and to parametrize the RO AP to our department's rating system. RESULTS An EBRT-PFMEA template comprising 75 high-risk failure modes could be compiled. The AIAG AP required 1.7 additional corrective actions per failure mode, while the RO AP ranged from 1.3 to 3.5, and the RPN required 3.6. The RO AP could be parametrized so that it suited our rating system and evaluated severity, occurrence, and detection ratings equally to the AIAG AP. CONCLUSIONS An adjustable EBRT-PFMEA template is provided which can be used as a practical starting point for creating institution-specific templates. Moreover, the RO AP introduces transparent action levels that can be adapted to any rating system.
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Affiliation(s)
- Dominik Kornek
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
| | - Christoph Bert
- Department of Radiation Oncology, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; Comprehensive Cancer Center Erlangen-EMN (CCC ER-EMN), 91054 Erlangen, Germany.
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9
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Wegener S, Exner F, Weick S, Stark S, Hutzel H, Lutyj P, Tamihardja J, Razinskas G. Prospective risk analysis of the online-adaptive artificial intelligence-driven workflow using the Ethos treatment system. Z Med Phys 2024; 34:384-396. [PMID: 36504142 DOI: 10.1016/j.zemedi.2022.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/20/2022] [Accepted: 11/14/2022] [Indexed: 12/13/2022]
Abstract
PURPOSE The recently introduced Varian Ethos system allows adjusting radiotherapy treatment plans to anatomical changes on a daily basis. The system uses artificial intelligence to speed up the process of creating adapted plans, comes with its own software solutions and requires a substantially different workflow. A detailed analysis of possible risks of the associated workflow is presented. METHODS A prospective risk analysis of the adaptive workflow with the Ethos system was performed using Failure Modes and Effects Analysis (FMEA). An interprofessional team collected possible adverse events and evaluated their severity as well as their chance of occurrence and detectability. Measures to reduce the risks were discussed. RESULTS A total of 122 events were identified, and scored. Within the 20 events with the highest-ranked risks, the following were identified: Challenges due to the stand-alone software solution with very limited connectivity to the existing record and verify software and digital patient file, unfamiliarity with the new software and its limitations and the adaption process relying on results obtained by artificial intelligence. The risk analysis led to the implementation of additional quality assurance measures in the workflow. CONCLUSIONS The thorough analysis of the risks associated with the new treatment technique was the basis for designing details of the workflow. The analysis also revealed challenges to be addressed by both, the vendor and customers. On the vendor side, this includes improving communication between their different software solutions. On the customer side, this especially includes establishing validation strategies to monitor the results of the black box adaption process making use of artificial intelligence.
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Affiliation(s)
- Sonja Wegener
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Florian Exner
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Stefan Weick
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Silke Stark
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Heike Hutzel
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Paul Lutyj
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Jörg Tamihardja
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
| | - Gary Razinskas
- University of Wuerzburg, Department of Radiation Oncology, Wuerzburg, Germany.
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10
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Seravalli E, Bosman ME, Han C, Losert C, Pazos M, Engström PE, Engellau J, Fulcheri CPL, Zucchetti C, Saldi S, Ferrer C, Ocanto A, Hiniker SM, Clark CH, Hussein M, Misson-Yates S, Kobyzeva DA, Loginova AA, Hoeben BAW. Technical recommendations for implementation of Volumetric Modulated Arc Therapy and Helical Tomotherapy Total Body Irradiation. Radiother Oncol 2024; 197:110366. [PMID: 38830537 DOI: 10.1016/j.radonc.2024.110366] [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: 01/25/2024] [Revised: 05/10/2024] [Accepted: 05/27/2024] [Indexed: 06/05/2024]
Abstract
As a component of myeloablative conditioning before allogeneic hematopoietic stem cell transplantation (HSCT), Total Body Irradiation (TBI) is employed in radiotherapy centers all over the world. In recent and coming years, many centers are changing their technical setup from a conventional TBI technique to multi-isocenter conformal arc therapy techniques such as Volumetric Modulated Arc Therapy (VMAT) or Helical Tomotherapy (HT). These techniques allow better homogeneity and control of the target prescription dose, and provide more freedom for individualized organ-at-risk sparing. The technical design of multi-isocenter/multi-plan conformal TBI is complex and should be developed carefully. A group of early adopters with conformal TBI experience using different treatment machines and treatment planning systems came together to develop technical recommendations and share experiences, in order to assist departments wishing to implement conformal TBI, and to provide ideas for standardization of practices.
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Affiliation(s)
- Enrica Seravalli
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Mirjam E Bosman
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Chunhui Han
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
| | - Christoph Losert
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Montserrat Pazos
- Department of Radiation Oncology, University Hospital, LMU Munich, Germany
| | - Per E Engström
- Department of Haematology, Oncology and Radiation Physics, Skåne University Hospital, Lund, Sweden
| | - Jacob Engellau
- Department of Radiation Oncology, Skåne University Hospital, Lund, Sweden
| | | | - Claudio Zucchetti
- Section of Medical Physics, Perugia General Hospital, Perugia, Italy
| | - Simonetta Saldi
- Section of Radiation Oncology, Perugia General Hospital, Perugia, Italy
| | - Carlos Ferrer
- Department of Medical Physics and Radiation Protection, La Paz University Hospital, Madrid, Spain
| | - Abrahams Ocanto
- Department of Radiation Oncology, San Francisco de Asís University Hospital, GenesisCare, Madrid, Spain
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University, Stanford, CA, USA
| | - Catharine H Clark
- Radiotherapy Physics, National Radiotherapy Trials Quality Assurance Group (RTTQA), Mount Vernon Cancer Centre, Northwood, UK; Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK; Radiotherapy Physics, University College London Hospitals NHS Foundation Trust, London, UK; Medical Physics and Bioengineering Department, University College London, London, UK
| | - Mohammad Hussein
- Metrology for Medical Physics Centre, National Physical Laboratory, Teddington, UK
| | - Sarah Misson-Yates
- Medical Physics Department, Guy's and St Thomas' Hospital, London, UK; UK School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK; National Physical Laboratory, Metrology for Medical Physics Centre, London, UK
| | - Daria A Kobyzeva
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Anna A Loginova
- Deptartment of Radiation Oncology, Dmitry Rogachev National Research Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Bianca A W Hoeben
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht, the Netherlands; Princess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands.
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11
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Kim LH, Juneja BR, Viscariello NN. A method for empirically validating FMEA RPN scores in a radiation oncology clinic using physics QC data. J Appl Clin Med Phys 2024; 25:e14391. [PMID: 38988053 PMCID: PMC11302802 DOI: 10.1002/acm2.14391] [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: 01/10/2024] [Revised: 04/02/2024] [Accepted: 04/22/2024] [Indexed: 07/12/2024] Open
Abstract
In failure modes and effects analysis (FMEA), the components of the risk priority number (RPN) for a failure mode (FM) are often chosen by consensus. We describe an empirical method for estimating the occurrence (O) and detectability (D) components of a RPN. The method requires for a given FM that its associated quality control measure be performed twice as is the case when a FM is checked for in an initial physics check and again during a weekly physics check. If instances of the FM caught by these checks are recorded, O and D can be computed. Incorporation of the remaining RPN component, Severity, is discussed. This method can be used as part of quality management design ahead of an anticipated FMEA or afterwards to validate consensus values.
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Affiliation(s)
- Leonard H. Kim
- Department of Radiation OncologyMD Anderson Cancer Center at CooperCamdenNew JerseyUSA
| | - Badal R. Juneja
- Department of Radiation OncologyMD Anderson Cancer Center at CooperCamdenNew JerseyUSA
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12
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Wegener S, Käthner P, Weick S, Schindhelm R, Breuer K, Stark S, Hutzel H, Lutyj P, Zimmermann M, Tamihardja J, Wittig A, Exner F, Razinskas G. Re-evaluation of the prospective risk analysis for artificial-intelligence driven cone beam computed tomography-based online adaptive radiotherapy after one year of clinical experience. Z Med Phys 2024; 34:397-407. [PMID: 38852003 DOI: 10.1016/j.zemedi.2024.05.001] [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: 02/05/2024] [Revised: 05/01/2024] [Accepted: 05/20/2024] [Indexed: 06/10/2024]
Abstract
Cone-beam computed tomography (CBCT)-based online adaptation is increasingly being introduced into many clinics. Upon implementation of a new treatment technique, a prospective risk analysis is required and enhances workflow safety. We conducted a risk analysis using Failure Mode and Effects Analysis (FMEA) upon the introduction of an online adaptive treatment programme (Wegener et al., Z Med Phys. 2022). A prospective risk analysis, lacking in-depth clinical experience with a treatment modality or treatment machine, relies on imagination and estimates of the occurrence of different failure modes. Therefore, we systematically documented all irregularities during the first year of online adaptation, namely all cases in which quality assurance detected undesired states potentially leading to negative consequences. Additionally, the quality of automatic contouring was evaluated. Based on those quantitative data, the risk analysis was updated by an interprofessional team. Furthermore, a hypothetical radiation therapist-only workflow during adaptive sessions was included in the prospective analysis, as opposed to the involvement of an interprofessional team performing each adaptive treatment. A total of 126 irregularities were recorded during the first year. During that time period, many of the previously anticipated failure modes (almost) occurred, indicating that the initial prospective risk analysis captured relevant failure modes. However, some scenarios were not anticipated, emphasizing the limits of a prospective risk analysis. This underscores the need for regular updates to the risk analysis. The most critical failure modes are presented together with possible mitigation strategies. It was further noted that almost half of the reported irregularities applied to the non-adaptive treatments on this treatment machine, primarily due to a manual plan import step implemented in the institution's workflow.
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Affiliation(s)
- Sonja Wegener
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany.
| | - Paul Käthner
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Stefan Weick
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Robert Schindhelm
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Kathrin Breuer
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Silke Stark
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Heike Hutzel
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Paul Lutyj
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Marcus Zimmermann
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Jörg Tamihardja
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Andrea Wittig
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Florian Exner
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
| | - Gary Razinskas
- University Hospital Würzburg, Department of Radiotherapy and Radiation Oncology, Josef-Schneider-Str. 11, 97080 Würzburg, Germany
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13
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Thomadsen B, Kapur A, Blankenship B, Caldwell B, Claps L, Cunningham J, Elee J, Evans S, Ford E, Gilley D, Hayden S, Hintenlang K, Kapoor R, Kildea J, Kroger L, Kujundzic K, Liang Q, Mutic S, O'Donovan A, O'Hara M, Ouhib Z, Palta J, Pawlicki T, Salter W, Schmidt S, Tripathi S. The report of AAPM task group 288: Recommendations for guiding radiotherapy event narratives. Med Phys 2024. [PMID: 39073127 DOI: 10.1002/mp.17282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 06/12/2024] [Indexed: 07/30/2024] Open
Abstract
Incident reporting and learning systems provide an opportunity to identify systemic vulnerabilities that contribute to incidents and potentially degrade quality. The narrative of an incident is intended to provide a clear, easy to understand description of an incident. Unclear, incomplete or poorly organized narratives compromise the ability to learn from them. This report provides guidance for drafting effective narratives, with particular attention to the use of narratives in incident reporting and learning systems (IRLS). Examples are given that compare effective and less than effective narratives. This report is mostly directed to organizations that maintain IRLS, but also may be helpful for individuals who desire to write a useful narrative for entry into such a system. Recommendations include the following: (1) Systems should allow a one- or two-sentence, free-text synopsis of an incident without guessing at causes; (2) Information included should form a sequence of events with chronology; and (3) Reporting and learning systems should consider using the headings suggested to guide the reporter through the narrative: (a) incident occurrences and actions by role; (b) prior circumstances and actions; (c) method by which the incident was identified; (d) equipment related details if relevant; (e) recovery actions by role; (f) relevant time span between responses; (g) and how individuals affected during or immediately after incident. When possible and appropriate, supplementary information including relevant data elements should be included using numerical scales or drop-down choices outside of the narrative. Information that should not be included in the narrative includes: (a) patient health information (PHI); (b) conjecture or blame; (c) jargon abbreviations or details without specifying their significance; (d) causal analysis.
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Affiliation(s)
- Bruce Thomadsen
- Department of Medical Physics, University of Wisconsin, Madison, Wisconsin, USA
| | - Ajay Kapur
- Department of Radiation Medicine, Northwell Health, Lake Success, New York, USA
| | | | - Barrett Caldwell
- Purdue University Schools of Industrial Engineering and Aeronautics & Astronautics, West Lafayette, Indiana, USA
| | - Lindsey Claps
- Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Jennifer Elee
- Conference of Radiation Control Program Directors, Inc., Sterlington, Louisiana, USA
| | - Suzanne Evans
- Therapeutic Radiology, Yale University, New Haven, Connecticut, USA
| | - Eric Ford
- Radiation Oncology, University of Washington, Seattle, Washington, USA
| | - Debbie Gilley
- International Atomic Energy Agency (retired), The Villages, Florida, USA
| | - Sandra Hayden
- Galveston College, Health Sciences, Galveston, Texas, USA
| | - Kathleen Hintenlang
- Department of Radiation Oncology, The Ohio State University, Columbus, Ohio, USA
| | - Rishabh Kapoor
- Department of Radiation Oncology, Virginia Commonwealth University Health System, Richmond, Virginia, USA
| | - John Kildea
- Medical Physics Unit, McGill University, Montréal, Québec, Canada
| | - Linda Kroger
- University of California Davis, Sacramento, California, USA
| | | | - Qing Liang
- Radiation Sciences, Actinium Pharmaceuticals, New York, New York, USA
| | - Sasa Mutic
- Radiation Oncology, Varian Medical Systems, Palo Alto, California, USA
| | - Anita O'Donovan
- Discipline of Radiation Therapy, Trinity College Dublin, Dublin, Ireland
| | - Michael O'Hara
- Division of Radiological Health, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Zoubir Ouhib
- Radiation Oncology, Florida Atlantic University, Boca Raton, Florida, USA
| | - Jatinder Palta
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Todd Pawlicki
- Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - William Salter
- Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Stacey Schmidt
- Northwestern Medicine Proton Center and West & North Region Cancer Centers, Warrenville, Illinois, USA
| | - Sugata Tripathi
- Radiation Oncology, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
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14
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Ma M, Li M, Zhang K, Ma P, Hu Z, Yan H, Men K, Dai J. Applying the six-sigma methodology to determine the limits of quality control (QC) tests for a specific linear accelerator. J Appl Clin Med Phys 2024:e14460. [PMID: 39072977 DOI: 10.1002/acm2.14460] [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: 12/24/2023] [Revised: 06/06/2024] [Accepted: 06/23/2024] [Indexed: 07/30/2024] Open
Abstract
PURPOSE We aimed to show the framework of the six-sigma methodology (SSM) that can be used to determine the limits of QC tests for the linear accelerator (Linac). Limits for QC tests are individually determined using the SSM. METHODS AND MATERIALS The SSM is based on the define-measure-analyze-improve-control (DMAIC) stages to improve the process. In the "define" stage, the limits of QC tests were determined. In the "measure" stage, a retrospective collection of daily QC data using a Machine Performance Check platform was performed from January 2020 to December 2022. In the "analyze" stage, the process of determining the limits was proposed using statistical analyses and process capability indices. In the "improve" stage, the capability index was used to calculate the action limits. The tolerance limit was established using the larger one of the control limits in the individual control chart (I-chart). In the "control" stage, daily QC data were collected prospectively from January 2023 to May 2023 to monitor the effect of action limits and tolerance limits. RESULTS A total of 798 sets of QC data including beam, isocenter, collimation, couch, and gantry tests were collected and analyzed. The Collimation Rotation offset test had the min-Cp, min-Cpk, min-Pp, and min-Ppk at 2.53, 1.99, 1.59, and 1.25, respectively. The Couch Rtn test had the max-Cp, max-Cpk, max-Pp, and max-Ppk at 31.5, 29.9, 23.4, and 22.2, respectively. There are three QC tests with higher action limits than the original tolerance. Some data on the I-chart of the beam output change, isocenter KV offset, and jaw X1 exceeded the lower tolerance and action limit, which indicated that a system deviation occurred and reminded the physicist to take action to improve the process. CONCLUSIONS The SSM is an excellent framework to use in determining the limits of QC tests. The process capability index is an important parameter that provides quantitative information on determining the limits of QC tests.
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Affiliation(s)
- Min Ma
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minghui Li
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ke Zhang
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Pan Ma
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihui Hu
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Yan
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kuo Men
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jianrong Dai
- National Cancer Center/National Clinical Research, Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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15
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Wong LM, Byrne M, van Dieren E, Zwart L, Ray X, Harms J, Aland T, Stanley D, Pawlicki T. Safety and Efficiency Analysis of Operational Decision-Making During Cone Beam Computed Tomography-Based Online Adaptive Radiation Therapy. Int J Radiat Oncol Biol Phys 2024; 119:1307-1316. [PMID: 38364949 DOI: 10.1016/j.ijrobp.2024.01.223] [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: 11/07/2023] [Revised: 01/06/2024] [Accepted: 01/28/2024] [Indexed: 02/18/2024]
Abstract
PURPOSE Cone beam computed tomography (CBCT)-based online adaptive radiation therapy (ART) is especially beneficial for patients with large interfractional anatomic changes. However, treatment planning and review decisions need to be made at the treatment console in real-time and may be delegated to clinical staff whose conventional scope of practice does not include making such decisions. Therefore, implementation can create new safety risks and inefficiencies. The objective of this work is to systematically analyze the safety and efficiency implications of human decision-making during the treatment session for CBCT-based online ART. METHODS AND MATERIALS The analysis was performed by applying the Systems-Theoretical Process Analysis technique and its extension for human decision-making. Four centers of different CBCT-based online ART practice models comprised the analysis team. RESULTS The general radiation therapy control structure was refined to model the interactions between routine treatment delivery staff and in-person or remote support staff. The treatment delivery staff perform 6 key control actions. Eighteen undesirable states of those control actions were identified as affecting safety and/or efficiency. In turn, 97 hazardous clinical scenarios were identified, with the control action "prepare and position patient" having the least number of scenarios and "delineate/edit influencer and target structures" having the most. Five of these are specific to either in-person or remote support during the treatment session, and 12 arise from staff support in general. CONCLUSIONS An optimally safe and efficient online ART program should require little to no support staff at the treatment console to reduce staff coordination. Uptraining of the staff already at the treatment console is needed to achieve this goal. Beyond the essential knowledge and skills such as contour editing and the selection of an optimal plan, uptraining should also target the specific cognitive biases identified in this work and the cognitive strategies to overcome these biases. Additionally, technological and organizational changes are necessary.
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Affiliation(s)
- Lawrence M Wong
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California.
| | - Mikel Byrne
- Icon Cancer Centre, South Brisbane, Queensland, Australia
| | - Erik van Dieren
- Department of Radiotherapy, Medical Spectrum Twente, Enschede, Netherlands
| | - Lisanne Zwart
- Department of Radiotherapy, Medical Spectrum Twente, Enschede, Netherlands
| | - Xenia Ray
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California
| | - Joseph Harms
- Department of Radiation Oncology/ Medical Physics, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Trent Aland
- Icon Cancer Centre, South Brisbane, Queensland, Australia
| | - Dennis Stanley
- Department of Radiation Oncology/ Medical Physics, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Todd Pawlicki
- Department of Radiation Medicine & Applied Sciences, University of California, San Diego, La Jolla, California
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16
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Sloop A, Ashraf MR, Rahman M, Sunnerberg J, Dexter CA, Thompson L, Gladstone DJ, Pogue BW, Bruza P, Zhang R. Rapid Switching of a C-Series Linear Accelerator Between Conventional and Ultrahigh-Dose-Rate Research Mode With Beamline Modifications and Output Stabilization. Int J Radiat Oncol Biol Phys 2024; 119:1317-1325. [PMID: 38552990 DOI: 10.1016/j.ijrobp.2024.01.215] [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: 04/24/2023] [Revised: 12/24/2023] [Accepted: 01/28/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE In this study, a C-series linear accelerator was configured to enable rapid and reliable conversion between the production of conventional electron beams and an ultrahigh-dose-rate (UHDR) electron beamline to the treatment room isocenter for FLASH radiation therapy. Efforts to tune the beam resulted in a consistent, stable UHDR beamline. METHODS AND MATERIALS The linear accelerator was configured to allow for efficient switching between conventional and modified electron output modes within 2 minutes. Additions to the air system allow for retraction of the x-ray target from the beamline when the 10 MV photon mode is selected. With the carousel set to an empty port, this grants access to the higher current pristine electron beam normally used to produce clinical photon fields. Monitoring signals related to the automatic frequency control system allows for tuning of the waveguide while the machine is in a hold state so a stable beam is produced from the initial pulse. A pulse counting system implemented on an field-programmable gate array-based controller platform controls the delivery to a desired number of pulses. Beam profiles were measured with Gafchromic film. Pulse-by-pulse dosimetry was measured using a custom electrometer designed around the EDGE diode. RESULTS This method reliably produces a stable UHDR electron beam. Open-field measurements of the 16-cm full-width, half-maximum gaussian beam saw average dose rates of 432 Gy/s at treatment isocenter. Pulse overshoots were limited and ramp up was eliminated. Over the last year, there have been no recorded incidents that resulted in machine downtime due to the UHDR conversions. CONCLUSIONS Stable 10 MeV UHDR beams were generated to produce an average dose rate of 432 Gy/s at the treatment room isocenter. With a reliable pulse-counting beam control system, consistent doses can be delivered for FLASH experiments with the ability to accommodate a wide range of field sizes, source-to-surface distances, and other experimental apparatus that may be relevant for future clinical translation.
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Affiliation(s)
- Austin Sloop
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - M Ramish Ashraf
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Mahbubur Rahman
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Jacob Sunnerberg
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | | | | | - David J Gladstone
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Dartmouth Health, New Hampshire, Lebanon; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire.
| | - Brian W Pogue
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Department of Medical Physics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Petr Bruza
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire
| | - Rongxiao Zhang
- Thayer School of Engineering, Dartmouth College, Hanover, New Hampshire; Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire; Department of Radiation Medicine, New York Medical College, Valhalla, New York
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Moncion A, Bryant AK, Cardenas CE, Dess KJ, Ditman MN, Mayo CS, Mierzwa ML, Paradis KC, Stanley DN, Covington EL. Quantifying the Risk of Technology-Driven Health Disparities in Radiation Oncology. Pract Radiat Oncol 2024:S1879-8500(24)00152-8. [PMID: 38992491 DOI: 10.1016/j.prro.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/21/2024] [Accepted: 06/04/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE New technologies are continuously emerging in radiation oncology. Inherent technological limitations can result in health care disparities in vulnerable patient populations. These limitations must be considered for existing and new technologies in the clinic to provide equitable care. MATERIALS AND METHODS We created a health disparity risk assessment metric inspired by failure mode and effects analysis. We provide sample patient populations and their potential associated disparities, guidelines for clinics and vendors, and example applications of the methodology. RESULTS A disparity risk priority number can be calculated from the product of 3 quantifiable metrics: the percentage of patients impacted, the severity of the impact of dosimetric uncertainty or quality of the radiation plan, and the clinical dependence on the evaluated technology. The disparity risk priority number can be used to rank the risk of suboptimal care due to technical limitations when comparing technologies and to plan interventions when technology is shown to have inequitable performance in the patient population of a clinic. CONCLUSIONS The proposed methodology may simplify the evaluation of how new technology impacts vulnerable populations, help clinics quantify the limitations of their technological resources, and plan appropriate interventions to improve equity in radiation treatments.
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Affiliation(s)
- Alexander Moncion
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Alex K Bryant
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiation Oncology, VA Ann Arbor Health System, Ann Arbor, Michigan
| | - Carlos E Cardenas
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Albama
| | - Kathryn J Dess
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiation Oncology, VA Ann Arbor Health System, Ann Arbor, Michigan
| | - Maria N Ditman
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan; Department of Radiation Oncology, VA Ann Arbor Health System, Ann Arbor, Michigan
| | - Charles S Mayo
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Michelle L Mierzwa
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Kelly C Paradis
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Dennis N Stanley
- Department of Radiation Oncology, The University of Alabama at Birmingham, Birmingham, Albama
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Hrbacek J, Kacperek A, Beenakker JWM, Mortimer L, Denker A, Mazal A, Shih HA, Dendale R, Slopsema R, Heufelder J, Mishra KK. PTCOG Ocular Statement: Expert Summary of Current Practices and Future Developments in Ocular Proton Therapy. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)00748-X. [PMID: 38971383 DOI: 10.1016/j.ijrobp.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 05/08/2024] [Accepted: 06/18/2024] [Indexed: 07/08/2024]
Abstract
Although rare cancers, ocular tumors are a threat to vision, quality of life, and potentially life expectancy of a patient. Ocular proton therapy (OPT) is a powerful tool for successfully treating this disease. The Particle Therapy Co-Operative Ocular Group) formulated an Evidence and Expert-Based Executive Summary of Current Practices and Future Developments in OPT: comparative dosimetric and clinical analysis with the different OPT systems is essential to set up planning guidelines, implement best practices, and establish benchmarks for eye preservation, vision, and quality of life measures. Contemporary prospective trials in select subsets of patients (eg, tumors near the optic disc and/or macula) may allow for dosimetric and clinical analysis between different radiation modalities and beamline systems to evaluate differences in radiation delivery and penumbra, and resultant tumor control, normal tissue complication rates, and overall clinical cost-effectiveness. To date, the combination of multimodal imaging (fundus photography, ultrasound, etc), ophthalmologist assessment, and clip surgery with radiation planning have been keys to successful treatment. Increased use of three-dimensional imaging (computed tomography/magnetic resonance imaging) is anticipated although its spatial resolution might be a limiting factor (eg, detection of flat diffuse tumor parts). Commercially produced ocular treatment-planning systems are under development and their future use is expected to expand across OPT centers. Future continuity of OPT will depend on the following: (1) maintaining and upgrading existing older dedicated low-energy facilities, (2) maintaining shared, degraded beamlines at large proton therapy centers, and (3) developing adapted gantry beams of sufficient quality to maintain the clinical benefits of sharp beam conformity. Option (1) potentially offers the sharpest beams, minimizing impact on healthy tissues, whereas (2) and (3) potentially offer the advantage of substantial long-term technical support and development as well as the introduction of new approaches. Significant patient throughputs and close cooperation between medical physics, ophthalmology, and radiation therapy, underpinned by mutual understanding, is crucial for a successful OPT service.
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Affiliation(s)
- Jan Hrbacek
- Center for Proton Therapy, Paul Scherrer Institute, Villigen, Switzerland.
| | | | - Jan-Willem M Beenakker
- Department of Ophthalmology, Leiden University Medical Center, Leiden, Netherlands; Department of Radiology, C.J. Gorter MRI Center, Leiden University Medical Center, Leiden, Netherlands; Department of Radiation Oncology, Leiden University Medical Center, Leiden, Netherlands; HollandPTC, Delft, Netherlands
| | - Linda Mortimer
- Medical Physics Department, The Clatterbridge Cancer Centre NHS Foundation Trust, Birkenhead, United Kingdom
| | - Andrea Denker
- Helmholtz-Zentrum Berlin für Materialien und Energie, Proton Therapy (BE-APT), Berlin, Germany
| | - Alejandro Mazal
- Medical Physics Service, Centro de Protonterapia Quironsalud, Madrid, Spain
| | - Helen A Shih
- Harvard Medical School, Boston, Massachusetts; Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Remi Dendale
- Institut Curie Protontherapy Center, Orsay, France
| | - Roelf Slopsema
- Department of Radiation Oncology, Emory Proton Therapy Center, Atlanta, Georgia
| | - Jens Heufelder
- Department of Ophthalmology, Charité - Universitätsmedizin Berlin, BerlinProtonen am HZB, Berlin, Germany
| | - Kavita K Mishra
- Proton Ocular Radiation Therapy Program, Department of Radiation Oncology, Osher Center for Integrative Health, Osher Foundation Endowed Chair in Clinical Programs in Integrative Health, University of California San Francisco, San Francisco, California
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Tan HQ, Koh CWY, Lew KS, Yeap PL, Chua CGA, Lee JKH, Wong YM, Wibawa A, Master Z, Lee JCL, Park SY. Repurposing DailyQA3 for an efficient and spot position sensitive daily quality assurance tool for proton therapy. J Appl Clin Med Phys 2024; 25:e14348. [PMID: 38561975 PMCID: PMC11244688 DOI: 10.1002/acm2.14348] [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: 12/09/2023] [Revised: 02/04/2024] [Accepted: 03/07/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION Daily quality assurance is an integral part of a radiotherapy workflow to ensure the dose is delivered safely and accurately to the patient. It is performed before the first treatment of the day and needs to be time and cost efficient for a multiple gantries proton center. In this study, we introduced an efficient method to perform QA for output constancy, range verification, spot positioning accuracy and imaging and proton beam isocenter coincidence with DailyQA3. METHODS A stepped acrylic block of specific dimensions is fabricated and placed on top of the DailyQA3 device. Treatment plans comprising of two different spread-out Bragg peaks and five individual spots of 1.0 MU each are designed to be delivered to the device. A mathematical framework to measure the 2D distance between the detectors and individual spot is introduced and play an important role in realizing the spot positioning and centering QA. Lastly, a 5 months trends of the QA for two gantries are presented. RESULTS The outputs are monitored by two ion chambers in the DailyQA3 and a tolerance of± 3 % $ \pm 3\% $ are used. The range of the SOBPs are monitored by the ratio of ion chamber signals and a tolerance of± 1 mm $ \pm 1\ {\mathrm{mm}}$ is used. Four diodes at± 10 cm $ \pm 10\ {\mathrm{cm}}$ from the central ion chambers are used for spot positioning QA, while the central ion chamber is used for imaging and proton beam isocenter coincidence QA. Using the framework, we determined the absolute signal threshold corresponding to the offset tolerance between the individual proton spot and the detector. A1.5 mm $1.5\ {\mathrm{mm}}$ tolerances are used for both the positioning and centering QA. No violation of the tolerances is observed in the 5 months trends for both gantries. CONCLUSION With the proposed approach, we can perform four QA items in the TG224 within 10 min.
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Affiliation(s)
- Hong Qi Tan
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Oncology Academic Clinical ProgrammeDuke‐NUS Medical SchoolSingaporeSingapore
| | - Calvin Wei Yang Koh
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - Kah Seng Lew
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Division of Physics and Applied PhysicsNanyang Technological UniversitySingaporeSingapore
| | - Ping Lin Yeap
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | | | | | - Yun Ming Wong
- Division of Physics and Applied PhysicsNanyang Technological UniversitySingaporeSingapore
| | - Andrew Wibawa
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - Zubin Master
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
| | - James Cheow Lei Lee
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Division of Physics and Applied PhysicsNanyang Technological UniversitySingaporeSingapore
| | - Sung Yong Park
- Division of Radiation OncologyNational Cancer Centre SingaporeSingaporeSingapore
- Oncology Academic Clinical ProgrammeDuke‐NUS Medical SchoolSingaporeSingapore
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Taneja S, Barbee DL. Implementation of an ionization chamber array for linear accelerator monthly dosimetry QA. J Appl Clin Med Phys 2024:e14433. [PMID: 38923344 DOI: 10.1002/acm2.14433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 05/07/2024] [Accepted: 06/02/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE The IC Profiler (ICP) manufactured by Sun Nuclear Corporation (SNC) is an ionization chamber (IC) array used for linear accelerator dosimetry measurements. Previous work characterized response of the ICP under various conditions, but there is limited work of its implementation into monthly QA measurement procedures. This work quantifies ICP accuracy and variables that affect accuracy for beam output measurements, and demonstrates feasibility of using the ICP for all recommended monthly dosimetry measurements. METHODS A total of 1985 output measurements on six Varian TrueBeam and Edge linear accelerators were performed using three ICP with quad wedges (QWs) and were compared with conventional IC measurements. The accuracy of the ICP for beam output was characterized as the difference between the ICP and IC. Variables that affect ICP accuracy, including gain settings, calibrations, and template baselining as well as machine or energy-specific bias were investigated. Measurements of profile constancy, energy, dose rate constancy, wedge factors, and gating were performed. RESULTS The initially observed mean output difference between the ICP and IC was 0.16% (0.61%). When gain settings were optimized, the output difference accuracy improved to -0.02% (0.38%). The output accuracy of the ICP was not dependent on array, dose, temperature and pressure calibrations, or template baselining. Statistically, ICP output accuracy was dependent on machine and beam energy, but clinically, all measurements fell within 0.5% of unity. ICP measurements of energy, dose rate constancy, and wedge factors matched passing results with conventional IC in water measurements. Gating and beam profile constancy measurements demonstrated good stability using the ICP. Finally, monthly dosimetry QA using ICP was completed in an average of 33 min compared to 66 min using the IC. CONCLUSION This work demonstrated the feasibility and efficiency of using the ICP, with specific considerations, as a measurement device for dosimetric linear accelerator monthly QA.
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Affiliation(s)
- Sameer Taneja
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York, USA
| | - David L Barbee
- Department of Radiation Oncology, New York University Langone Medical Center, New York, New York, USA
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Benavente S, Giraldo A, Seoane A, Ramos M, Vergés R. Clinical effects of re-evaluating a lung SBRT failure mode and effects analysis in a radiotherapy department. Clin Transl Oncol 2024:10.1007/s12094-024-03539-9. [PMID: 38831192 DOI: 10.1007/s12094-024-03539-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Accepted: 05/24/2024] [Indexed: 06/05/2024]
Abstract
PURPOSE The increasing complexity of radiation treatments can hinder its clinical success. This study aimed to better understand evolving risks by re-evaluating a Failure Mode and Effects Analysis (FMEA) in lung SBRT. METHODS An experienced multidisciplinary team conducted an FMEA and made a reassessment 3 years later. A process map was developed with potential failure modes (FMs) identified. High-risk FMs and their possible causes and corrective actions were determined. The initial FMEA analysis was compared to gain a deeper perspective. RESULTS We identified 232 FMs. The high-risk processes were plan approval, target contouring, and patient evaluation. The corrective measures were based on stricter standardization of plan approval, pre-planning peer review, and a supporting pretreatment checklist, which substantially reduced the risk priority number in the revised FMEA. In the FMEA reassessment, we observed that the increased complexity and number of patients receiving lung SBRT conditioned a more substantial presence of human factors and communication errors as causal conditions and a potential wrong dose as a final effect. CONCLUSIONS Conducting a lung SBRT FMEA analysis has identified high-risk conditions that have been effectively mitigated in an FMEA reanalysis. Plan approval has shown to be a weak link in the process. The increasing complexity of treatments and patient numbers have shifted causal factors toward human failure and communication errors. The potential of a wrong dose as a final effect augments in this scenario. We propose that digital and artificial intelligence options are needed to mitigate potential errors in high-complexity and high-risk RT scenarios.
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Affiliation(s)
- Sergi Benavente
- Department of Radiation Oncology, Vall d'Hebron University Hospital Campus, Barcelona, Spain.
| | - Alexandra Giraldo
- Department of Radiation Oncology, Vall d'Hebron University Hospital Campus, Barcelona, Spain
| | - Alejandro Seoane
- Department of Medical Physics and Radiation Protection, Vall d'Hebron University Hospital Campus, Barcelona, Spain
| | - Mónica Ramos
- Department of Radiation Oncology, Vall d'Hebron University Hospital Campus, Barcelona, Spain
| | - Ramona Vergés
- Department of Radiation Oncology, Vall d'Hebron University Hospital Campus, Barcelona, Spain
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Tan HQ, Koh CWY, Lew KS, Yeap PL, Chua CGA, Lee JKH, Wibawa A, Master Z, Lee JCL, Park SY. Real-time gated proton therapy with a reduced source to imager distance: Commissioning and quality assurance. Phys Med 2024; 122:103380. [PMID: 38805761 DOI: 10.1016/j.ejmp.2024.103380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/12/2024] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
INTRODUCTION Real-time gated proton therapy (RGPT) is a motion management technique unique to the Hitachi particle therapy system. It uses pulsed fluoroscopy to track an implanted fiducial marker. There are currently no published guidelines on how to conduct the commissioning and quality assurance. In this work we reported on our centre's commissioning workflow and our daily and monthly QA procedures. METHODS Six commissioning measurements were designed for RGPT. The measurements include imaging qualities, fluoroscopic exposures, RGPT marker tracking accuracy, temporal gating latency, fiducial marker tracking fidelity and an end-to-end proton dosimetry measurement. Daily QA consists of one measurement on marker localization accuracy. Four months daily QA trends are presented. Monthly QA consists of three measurementson the gating latency, fluoroscopy imaging quality and dosimetry verification of gating operation with RGPT. RESULTS The RGPT was successfully commissioned in our centre. The air kerma rates were within 15 % from specifications and the marker tracking accuracies were within 0.245 mm. The gating latencies for turning the proton beam on and off were 119.5 and 50.0 ms respectively. The 0.4x10.0 mm2 Gold AnchorTM gave the best tracking results with visibility up to 30 g/cm2. Gamma analysis showed that dose distribution of a moving and static detectors had a passing rate of more than 95 % at 3 %/3mm. The daily marker localization QA results were all less than 0.2 mm. CONCLUSION This work could serve as a good reference for other upcoming Hitachi particle therapy centres who are interested to use RGPT as their motion management solution.
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Affiliation(s)
- Hong Qi Tan
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore.
| | | | - Kah Seng Lew
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Ping Lin Yeap
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | | | - Andrew Wibawa
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | - Zubin Master
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore
| | | | - Sung Yong Park
- Division of Radiation Oncology, National Cancer Centre Singapore, Singapore; Oncology Academic Clinical Programme, Duke-NUS Medical School, Singapore
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Hobson MA, Hu Y, Caldwell B, Cohen GN, Glide-Hurst C, Huang L, Jackson PD, Jang S, Langner U, Lee HJ, Levesque IR, Narayanan S, Park JC, Steffen J, Wu QJ, Zhou Y. AAPM Task Group 334: A guidance document to using radiotherapy immobilization devices and accessories in an MR environment. Med Phys 2024; 51:3822-3849. [PMID: 38648857 PMCID: PMC11330642 DOI: 10.1002/mp.17061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 11/13/2023] [Accepted: 03/28/2024] [Indexed: 04/25/2024] Open
Abstract
Use of magnetic resonance (MR) imaging in radiation therapy has increased substantially in recent years as more radiotherapy centers are having MR simulators installed, requesting more time on clinical diagnostic MR systems, or even treating with combination MR linear accelerator (MR-linac) systems. With this increased use, to ensure the most accurate integration of images into radiotherapy (RT), RT immobilization devices and accessories must be able to be used safely in the MR environment and produce minimal perturbations. The determination of the safety profile and considerations often falls to the medical physicist or other support staff members who at a minimum should be a Level 2 personnel as per the ACR. The purpose of this guidance document will be to help guide the user in making determinations on MR Safety labeling (i.e., MR Safe, Conditional, or Unsafe) including standard testing, and verification of image quality, when using RT immobilization devices and accessories in an MR environment.
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Affiliation(s)
- Maritza A Hobson
- Department of Radiation Oncology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Yanle Hu
- Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | - Barrett Caldwell
- School of Industrial Engineering, Purdue University, West Lafayette, Indiana, USA
- School of Aeronautics and Astronautics, Purdue University, West Lafayette, Indiana, USA
| | - Gil'ad N Cohen
- Department of Medical Physics, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
| | - Carri Glide-Hurst
- Department of Human Oncology, University of Wisconsin--Madison, Madison, Wisconsin, USA
- Department of Medical Physics, University of Wisconsin--Madison, Madison, Wisconsin, USA
| | - Long Huang
- Department of Radiation Oncology, University of Utah, Salt Lake City, Utah, USA
| | - Paul D Jackson
- Department of Radiation Oncology, Henry Ford Health System, Detroit, Michigan, USA
| | - Sunyoung Jang
- Department of Radiation Oncology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Ulrich Langner
- Department of Radiation Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Hannah J Lee
- Corewell Health William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - Ives R Levesque
- Gerald Bronfman Department of Oncology and Medical Physics Unit, McGill University, Montreal, QC, Canada
- Department of Medical Physics, McGill University Health Centre, Cedars Cancer Centre, Montreal, QC, Canada
| | - Sreeram Narayanan
- Department of Radiation Oncology, Virginia Mason Cancer Institute, Seattle, Washington, USA
| | - Justin C Park
- Division of Medical Physics, Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Q Jackie Wu
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Yong Zhou
- Department of Radiology Services, Corewell Health, Grand Rapids, Michigan, USA
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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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Yuen J, Batool M, Baldock C. Proactive risk management should be mandatory for the setup of new techniques in radiation oncology. Phys Eng Sci Med 2024:10.1007/s13246-024-01446-5. [PMID: 38809366 DOI: 10.1007/s13246-024-01446-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Affiliation(s)
- Johnson Yuen
- St George Hospital Cancer Care Centre, Kogarah, NSW, 2217, Australia
- South Western Clinical School, University of New South Wales, Sydney, Australia
- Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Misbah Batool
- Department of Physics & Applied Mathematics, PIEAS, Nilore, Islamabad, Pakistan
| | - Clive Baldock
- Graduate Research School, Western Sydney University, Penrith, NSW, 2747, Australia.
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Jeong S, Pyo H, Park W, Han Y. The Prediction of Stress in Radiation Therapy: Integrating Artificial Intelligence with Biological Signals. Cancers (Basel) 2024; 16:1964. [PMID: 38893087 PMCID: PMC11171009 DOI: 10.3390/cancers16111964] [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: 03/27/2024] [Revised: 05/17/2024] [Accepted: 05/20/2024] [Indexed: 06/21/2024] Open
Abstract
This study aimed to predict stress in patients using artificial intelligence (AI) from biological signals and verify the effect of stress on respiratory irregularity. We measured 123 cases in 41 patients and calculated stress scores with seven stress-related features derived from heart-rate variability. The distribution and trends of stress scores across the treatment period were analyzed. Before-treatment information was used to predict the stress features during treatment. AI models included both non-pretrained (decision tree, random forest, support vector machine, long short-term memory (LSTM), and transformer) and pretrained (ChatGPT) models. Performance was evaluated using 10-fold cross-validation, exact match ratio, accuracy, recall, precision, and F1 score. Respiratory irregularities were calculated in phase and amplitude and analyzed for correlation with stress score. Over 90% of the patients experienced stress during radiation therapy. LSTM and prompt engineering GPT4.0 had the highest accuracy (feature classification, LSTM: 0.703, GPT4.0: 0.659; stress classification, LSTM: 0.846, GPT4.0: 0.769). A 10% increase in stress score was associated with a 0.286 higher phase irregularity (p < 0.025). Our research pioneers the use of AI and biological signals for stress prediction in patients undergoing radiation therapy, potentially identifying those needing psychological support and suggesting methods to improve radiotherapy effectiveness through stress management.
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Affiliation(s)
- Sangwoon Jeong
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul 06355, Republic of Korea;
| | - Hongryull Pyo
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06355, Republic of Korea; (H.P.); (W.P.)
- School of Medicine, Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06355, Republic of Korea; (H.P.); (W.P.)
- School of Medicine, Sungkyunkwan University, Seoul 06355, Republic of Korea
| | - Youngyih Han
- Department of Health Sciences and Technology, SAIHST, Sungkyunkwan University, Seoul 06355, Republic of Korea;
- Department of Radiation Oncology, Samsung Medical Center, Seoul 06355, Republic of Korea; (H.P.); (W.P.)
- School of Medicine, Sungkyunkwan University, Seoul 06355, Republic of Korea
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Lu QP, Wu Y, Mao XD, Wan HJ, Shao J, Yu QK, Zhang W, Zhao Y, Wang CY. Continuous quality improvement project to reduce the downtime of medical linear accelerators: A case study at Zhejiang Cancer Hospital. Heliyon 2024; 10:e30668. [PMID: 38774097 PMCID: PMC11107096 DOI: 10.1016/j.heliyon.2024.e30668] [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: 11/10/2023] [Revised: 03/28/2024] [Accepted: 05/01/2024] [Indexed: 05/24/2024] Open
Abstract
Objective To analyse and continually improve existing issues in the quality improvement process of medical linear accelerators (LINACs) and enhance the quality control management of LINACs. Methods Data were collected from eight LINACs (sourced from three manufacturers) at Zhejiang Cancer Hospital using Excel diaries between January 2019 and December 2020. The data description and analysis were performed using the analytic hierarchy process, SPSSAU and Excel software, and mean-time-to-repair (MTTR)/mean-time-between-failure (MTBF) metrics. Continuous quality improvement was executed using the quality control circle (QCC) quality management method. Results After quality improvement, the risk frequency of 'LINAC down' events decreased by 43.63% and downtime was reduced by 40.45%. The weight of downtime risk improved by 73.69%. The MTTR recovery value increased by 31.90%, and MTBF reliability increased by 2.97 h. The simulation results demonstrated that the proposed quality improvement measures could effectively decrease the frequency and duration of downtimes, consequently extending the normal operational time of LINACs. Conclusion Transitioning from instant repair to preventative maintenance can enhance the operational efficiency of equipment and yield economic benefits for hospitals. The QCC method and the event risk evaluation model are effective in reducing the downtime of LINACs and improving their quality control management.
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Affiliation(s)
- Qi-Peng Lu
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Yong Wu
- Department of Purchasing, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Xiao-Dong Mao
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Hua-Jun Wan
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Jian Shao
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Qi-Kai Yu
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Wei Zhang
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Yue Zhao
- Department of Purchasing, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
| | - Ci-Yong Wang
- Department of Medical Engineering, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), 310022, Hangzhou, China
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Saw CB, Battin F, Churilla T, Haggerty M, Peters CA. TEAM participation in the irradiation of IROC phantoms for cooperative group clinical trials. Med Dosim 2024:S0958-3947(24)00019-0. [PMID: 38735780 DOI: 10.1016/j.meddos.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/16/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024]
Abstract
The participation of radiation oncology team members in the irradiation of Imaging and Radiation Oncology Core (IROC) phantom for cooperative group clinical trials is essential to comply with the latest quality management philosophy. Medical dosimetrists are expected to develop treatment plans for the irradiation of IROC phantoms. For advanced treatment techniques, such as three-dimensional conformal radiation therapy (3DCRT), intensity-modulated radiation therapy (IMRT), and volumetric-modulated arc therapy (VMAT), the irradiation of the IROC phantoms serves as quality audit. If successful, the irradiation processes demonstrate that the institution has the knowledge of the protocol, and has the appropriate equipment to comply with the protocol requirements. This article describes three IROC phantoms used for credentialing external beam photon beam therapy, delivered using conventional medical linear accelerators, to the medical dosimetry community. Guidance and strategies for the development of treatment plans are discussed. Our institutional irradiation of the three IROC phantoms, delivered using the Truebeam medical linear accelerator, resulted in consistent dose accuracy to within ±1%. The participation of the team members may reduce the overall published failing rate stated to be about one-third of all participating institutions.
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Affiliation(s)
- Cheng B Saw
- Northeast Radiation Oncology Centers (NROC), Dunmore, PA 18512, USA.
| | - Frank Battin
- Northeast Radiation Oncology Centers (NROC), Dunmore, PA 18512, USA
| | - Thomas Churilla
- Northeast Radiation Oncology Centers (NROC), Dunmore, PA 18512, USA
| | - Meghan Haggerty
- Northeast Radiation Oncology Centers (NROC), Dunmore, PA 18512, USA
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Holtman AL, DiCostanzo DJ, Zimmerman CA, Graeper G, Woollard J, Christ DF, Cetnar AJ. Comparison of failure modes and effects analyses and time for brachytherapy ring and tandem applicator digitization between manual and solid applicator source placement methods. J Appl Clin Med Phys 2024; 25:e14336. [PMID: 38664983 PMCID: PMC11087182 DOI: 10.1002/acm2.14336] [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: 07/19/2023] [Revised: 02/17/2024] [Accepted: 03/05/2024] [Indexed: 05/12/2024] Open
Abstract
PURPOSE Ring and tandem (R&T) applicator digitization is currently performed at our institution by manually defining the extent of the applicators. Digitization can also be achieved using solid applicators: predefined, 3D models with geometric constraints. This study compares R&T digitization using manual and solid applicator methods through Failure Modes and Effects Analyses (FMEAs) and comparative time studies. We aim to assess the suitability of solid applicator method implementation for R&T cases METHODS: Six qualified medical physicists (QMPs) and two medical physics residents scored potential modes of failure of manual digitization in an FMEA as recommended by TG-100. Occurrence, severity, and detectability (OSD) values were averaged across respondents and then multiplied to form combined Risk Priority Numbers (RPNs) for analysis. Participants were trained to perform treatment planning using a developed solid applicator protocol and asked to score a second FMEA on the distinct process steps from the manual method. For both methods, participant digitization was timed. FMEA and time data were analyzed across methods and participant samples RESULTS: QMPs rated the RPNs of the current, manual method of digitization statistically lower than residents did. When comparing the unique FMEA steps between the two digitization methods, QMP respondents found no significant difference in RPN means. Residents, however, rated the solid applicator method as higher risk. Further, after the solid applicator method was performed twice by participants, the time to digitize plans was not significantly different from manual digitization CONCLUSIONS: This study indicates the non-inferiority of the solid applicator method to manual digitization in terms of risk, according to QMPs, and time, across all participants. Differences were found in FMEA evaluation and solid applicator technique adoption based on years of brachytherapy experience. Further practice with the solid applicator protocol is recommended because familiarity is expected to lower FMEA occurrence ratings and further reduce digitization times.
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Affiliation(s)
- Adia L. Holtman
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | | | | | - Gavin Graeper
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | - Jeffrey Woollard
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | - Daniel F. Christ
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | - Ashley J. Cetnar
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
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Mercolli L, Rominger A, Shi K. Towards quality management of artificial intelligence systems for medical applications. Z Med Phys 2024; 34:343-352. [PMID: 38413355 PMCID: PMC11156774 DOI: 10.1016/j.zemedi.2024.02.001] [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: 10/17/2022] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/29/2024]
Abstract
The use of artificial intelligence systems in clinical routine is still hampered by the necessity of a medical device certification and/or by the difficulty of implementing these systems in a clinic's quality management system. In this context, the key questions for a user are how to ensure robust model predictions and how to appraise the quality of a model's results on a regular basis. In this paper we discuss some conceptual foundation for a clinical implementation of a machine learning system and argue that both vendors and users should take certain responsibilities, as is already common practice for high-risk medical equipment. We propose the methodology from AAPM Task Group 100 report No. 283 as a conceptual framework for developing risk-driven a quality management program for a clinical process that encompasses a machine learning system. This is illustrated with an example of a clinical workflow. Our analysis shows how the risk evaluation in this framework can accommodate artificial intelligence based systems independently of their robustness evaluation or the user's in-house expertise. In particular, we highlight how the degree of interpretability of a machine learning system can be systematically accounted for within the risk evaluation and in the development of a quality management system.
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Affiliation(s)
- Lorenzo Mercolli
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland.
| | - Axel Rominger
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Kuangyu Shi
- Department of Nuclear Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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Nishioka S, Okamoto H, Chiba T, Kito S, Ishihara Y, Isono M, Ono T, Mizoguchi A, Mizuno N, Tohyama N, Kurooka M, Ota S, Shimizu D. Technical note: A universal worksheet for failure mode and effects analysis-A project of the Japanese College of Medical Physics. Med Phys 2024; 51:3658-3664. [PMID: 38507277 DOI: 10.1002/mp.17033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Failure mode and effects analysis (FMEA), which is an effective tool for error prevention, has garnered considerable attention in radiotherapy. FMEA can be performed individually, by a group or committee, and online. PURPOSE To meet the needs of FMEA for various purposes and improve its accessibility, we developed a simple, self-contained, and versatile web-based FMEA risk analysis worksheet. METHODS We developed an FMEA worksheet using Google products, such as Google Sheets, Google Forms, and Google Apps Script. The main sheet was created in Google Sheets and contained elements necessary for performing FMEA by a single person. Automated tasks were implemented using Apps Script to facilitate multiperson FMEA; these functions were built into buttons located on the main sheet. RESULTS The usability of the FMEA worksheet was tested in several situations. The worksheet was feasible for individual, multiperson, seminar, meeting, and online purposes. Simultaneous online editing, automated survey form creation, automatic analysis, and the ability to respond to the form from multiple devices, including mobile phones, were particularly useful for online and multiperson FMEA. Automation enabled through Google Apps Script reduced the FMEA workload. CONCLUSIONS The FMEA worksheet is versatile and has a seamless workflow that promotes collaborative work for safety.
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Affiliation(s)
- Shie Nishioka
- Department of Radiation Oncology, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Takahito Chiba
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, Tokyo, Japan
| | - Satoshi Kito
- Division of Radiation Oncology, Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Yoshitomo Ishihara
- Department of Radiation Oncology, Division of Medical Physics, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Masaru Isono
- Department of Radiation Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Tomohiro Ono
- Department of Radiation Oncology and Image-Applied Therapy, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Asumi Mizoguchi
- Department of Radiology, Kurume University Hospital, Fukuoka, Japan
| | - Norifumi Mizuno
- Department of Radiation Oncology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Makuhari Clinic for Advanced Imaging, Cancer Screening, and High-Precision Radiotherapy, Chiba, Japan
| | - Masahiko Kurooka
- Department of Radiation Therapy, Tokyo Medical University Hospital, Tokyo, Japan
| | - Seiichi Ota
- Department of Medical Technology, University Hospital, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Daisuke Shimizu
- Department of Radiation Oncology, Kyoto Second Red Cross Hospital, Kyoto, Japan
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Dhoundiyal M, Rasal S, Gupte A, Dandekar PR, Jadhav A, Awate O. Validation and Efficiency Evaluation of Automated Quality Assurance Software SunCHECK™ Machine for Mechanical and Dosimetric Quality Assurance. J Med Phys 2024; 49:311-315. [PMID: 39131425 PMCID: PMC11309146 DOI: 10.4103/jmp.jmp_158_23] [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: 11/17/2023] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 08/13/2024] Open
Abstract
Recent decades have witnessed transformative advances in radiation physics and computer technology, revolutionizing the precision of radiation therapy. The adoption of intricate treatment techniques such as three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, volumetric-modulated arc therapy, and image-guided radiotherapy necessitates robust quality assurance (QA) programs. This study introduces the SunCHECK™ Machine (SCM), a web-based QA platform, presenting early results from its integration into a comprehensive QA program. linear accelerators (LINAC) demand QA programs to uphold machine characteristics within accepted tolerances. The increasing treatment complexity underscores the need for streamlined procedures. The selection of QA tools is vital, requiring efficiency, accuracy, and alignment with clinic needs, as per recommendations such as the AAPM task group 142 report. The materials and methods section details SCM implementation in various QA aspects, encompassing daily QA (DQA), imaging QA with Catphan, conventional output assessment with a water phantom, and LINAC isocenter verification through the Winston-Lutz test. Challenges in QA processes, such as manual data transcription and limited device integration, are highlighted. Early results demonstrate SCM's significant reduction in QA time, ensuring accuracy and efficiency. Its automation eliminates interobserver variation and human errors, contributing to time savings and near-immediate result publication. SCM's role in consolidating and storing DQA data within a single platform is emphasized, offering potential in resource optimization, especially in resource-limited settings. In conclusion, SCM shows promise for efficient and accurate mechanical and dosimetric QA in radiation therapy. The study underscores SCM's potential to address contemporary QA challenges, contributing to improved resource utilization without compromising quality and safety standards.
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Affiliation(s)
- Mayank Dhoundiyal
- Department of Radiation Oncology, Sir H.N Reliance Foundation and Research Centre, Mumbai, Maharashtra, India
| | - Sachin Rasal
- Department of Radiation Oncology, Sir H.N Reliance Foundation and Research Centre, Mumbai, Maharashtra, India
| | - Ajinkya Gupte
- Department of Radiation Oncology, Sir H.N Reliance Foundation and Research Centre, Mumbai, Maharashtra, India
| | - Prasad Raj Dandekar
- Department of Radiation Oncology, Sir H.N Reliance Foundation and Research Centre, Mumbai, Maharashtra, India
| | - Ananda Jadhav
- Department of Radiation Oncology, Sir H.N Reliance Foundation and Research Centre, Mumbai, Maharashtra, India
| | - Omkar Awate
- Department of Radiation Oncology, Sir H.N Reliance Foundation and Research Centre, Mumbai, Maharashtra, India
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Swanson AE, DiCostanzo DJ, Gupta N, Hintenlang K, Chakravarti A, Cetnar AJ. Multi-phase failure modes and effects analysis for low dose bilateral whole lung irradiation of COVID-19 positive patients requiring respiratory ventilation. J Appl Clin Med Phys 2024; 25:e14261. [PMID: 38194600 PMCID: PMC11005974 DOI: 10.1002/acm2.14261] [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: 05/19/2023] [Revised: 10/31/2023] [Accepted: 12/10/2023] [Indexed: 01/11/2024] Open
Abstract
PURPOSE To identify high-priority risks in a clinical trial investigating the use of radiation to alleviate COVID-19 pneumonia using a multi-phase failure modes and effects analysis (FMEA). METHODS A comprehensive FMEA survey of 133 possible causes of failure was developed for the clinical trial workflow (Phase I). The occurrence, severity, and detection risk of each possible cause of failure was scored by three medical physicists. High-risk potential failure modes were identified using the risk priority number (RPN) and severity scores, which were re-scored by 13 participants in radiation oncology (Phase II). Phase II survey scores were evaluated to identify steps requiring possible intervention and examine risk perception patterns. The Phase II participants provided consensus scores as a group. RESULTS Thirty high-priority failure modes were selected for the Phase II survey. Strong internal consistency was shown in both surveys using Cronbach's alpha (αc ≥ 0.85). The 10 failures with the largest median RPN values concerned SARS-CoV-2 transmission (N = 6), wrong treatment (N = 3), and patient injury (N = 1). The median RPN was larger for COVID-related failures than other failure types, primarily due to the perceived difficulty of failure detection. Group re-scoring retained 8/10 of the highest-priority risk steps that were identified in the Phase II process, and discussion revealed interpretation differences of process steps and risk evaluation. Participants who were directly involved with the trial working group had stronger agreement on severity scores than those who were not. CONCLUSIONS The high ranking of failures concerning SARS-CoV-2 transmission suggest that these steps may require additional quality management intervention when treating critically ill COVID-19+ patients. The results also suggest that a multi-phase FMEA survey led by a facilitator may be a useful tool for assessing risks in radiation oncology procedures, supporting future efforts to adapt FMEA to clinical procedures.
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Affiliation(s)
- Amanda E. Swanson
- Department of Radiation MedicineOregon Health & Science UniversityPortlandOregonUSA
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | | | - Nilendu Gupta
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | | | - Arnab Chakravarti
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
| | - Ashley J. Cetnar
- Department of Radiation OncologyThe Ohio State UniversityColumbusOhioUSA
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Yoshida T, Hayakawa T, Kawadai T, Shibasaki T. [Implementation and Effectiveness of Measures to Prevent Recurrence of Incidents Developed through Root Cause Analysis Using Work Flowchart]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2024; 80:304-310. [PMID: 38296466 DOI: 10.6009/jjrt.2024-1431] [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] [Indexed: 03/22/2024]
Abstract
PURPOSE Incidents are recommended to be analyzed by root cause analysis (RCA). Our institution also conducts RCA for incidents and takes measures to prevent recurrence. The purpose of this study was to evaluate the effectiveness of countermeasures against the root causes analyzed by RCA in order to prevent recurrence of incidents. METHODS Since the treatment planning CT scanner was replaced, incidents of failure to zero adjustment the coordinates of the bed position occurred four times during a three-month period. The RCA was used to investigate the root causes of these incidents and to formulate measures to prevent recurrence. To evaluate the effectiveness of the recurrence prevention measures, we collected the number of recurrence of incidents during the first year after the effectiveness of the recurrence prevention measures, and used the chi-square test to determine the significant difference in the probability of an incident occurring at a significance level of 5% or less. RESULTS The measures to prevent the recurrence of incidents were to double-check that the coordinates of the bed position were adjusted to zero and to simulate operations based on a work flow that incorporated this double-check. During the first year period following the implementation of these recurrence prevention measures, the number of recurrence incidents was zero, and the probability of their occurrence decreased statistically significantly (p<0.05). CONCLUSION Thorough double-checks and work simulation based on the work flow are effective methods for preventing the recurrence of incidents.
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Affiliation(s)
- Tatsuya Yoshida
- Department of Radiology, Tatebayashi Kosei General Hospital
- Graduate School of Radiological Technology, Gunma Prefectural College of Health Sciences
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Samanci Y, Askeroglu MO, Düzkalir AH, Peker S. Assessing the impact of distortion correction on Gamma Knife radiosurgery for multiple metastasis: Volumetric and dosimetric analysis. BRAIN & SPINE 2024; 4:102791. [PMID: 38584868 PMCID: PMC10995810 DOI: 10.1016/j.bas.2024.102791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 03/11/2024] [Accepted: 03/19/2024] [Indexed: 04/09/2024]
Abstract
Introduction Magnetic resonance imaging (MRI) is a robust neuroimaging technique and is the preferred method for stereotactic radiosurgery (SRS) planning. However, MRI data always contain distortions caused by hardware and patient factors. Research question Can these distortions potentially compromise the effectiveness and safety of SRS treatments? Material and methods Twenty-six MR datasets with multiple metastatic brain tumors (METs) used for Gamma Knife radiosurgery (GKRS) were retrospectively evaluated. A commercially available software was used for distortion correction. Geometrical agreement between corrected and uncorrected tumor volumes was evaluated using MacDonald criteria, Euclidian distance, and Dice similarity coefficient (DSC). SRS plans were generated using uncorrected tumor volumes, which were assessed to determine their coverage of the corrected tumor volumes. Results The median target volume was 0.38 cm3 (range,0.01-12.38 cm3). A maximum displacement of METs of up to 2.87 mm and a median displacement of 0.55 mm (range,0.1-2.87 mm) were noted. The median DSC between uncorrected and corrected MRI was 0.92, and the most concerning case had a DSC of 0.46. Although all plans met the optimization criterion of at least 98% of the uncorrected tumor volume (median 99.55%, range 98.1-100%) receiving at least 100% of the prescription dose, the percent of the corrected tumor volume receiving the total prescription dose was a median of 95.45% (range,23.1-99.5%). Discussion and conclusion MRI distortion, though visually subtle, has significant implications for SRS planning. Regular utilization of corrected MRI is recommended for SRS planning as distortion is sometimes enough to cause a volumetric miss of SRS targets.
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Affiliation(s)
- Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
- Gamma Knife Center, Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
| | - M. Orbay Askeroglu
- Gamma Knife Center, Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
| | - Ali Haluk Düzkalir
- Gamma Knife Center, Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
- Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
- Gamma Knife Center, Department of Neurosurgery, Koc University Hospital, Istanbul, Turkey
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Vinogradskiy Y, Schubert L, Taylor A, Rudoler S, Lamb J. Radiation Oncology Ransomware Attack Response Risk Analysis Using Failure Modes and Effects Analysis. Pract Radiat Oncol 2024:S1879-8500(24)00044-4. [PMID: 38508451 DOI: 10.1016/j.prro.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 03/04/2024] [Accepted: 03/06/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE There have been numerous significant ransomware attacks impacting Radiation Oncology in the past 5 years. Research into ransomware attack response in Radiation Oncology has consisted of case reports and descriptive articles and has lacked quantitative studies. The purpose of this work was to identify the significant safety risks to patients being treated with radiation therapy during a ransomware attack scenario, using Failure Modes and Effects Analysis. METHODS AND MATERIALS A multi-institutional and multidisciplinary team conducted a Failure Modes and Effects Analysis by developing process maps and using Risk Priority Number (RPN) scores to quantify the increased likelihood of incidents in a ransomware attack scenario. The situation that was simulated was a ransomware attack that had removed the capability to access the Record and Verify (R&V) system. Five situations were considered: 1) a standard treatment of a patient with and without an R&V, 2) a standard treatment of a patient for the first fraction right after the R&V capabilities are disabled, and 3) 3 situations in which a plan modification was required. RPN scores were compared with and without R&V functionality. RESULTS The data indicate that RPN scores increased by 71% (range, 38%-96%) when R&V functionality is disabled compared with a nonransomware attack state where R&V functionality is available. The failure modes with the highest RPN in the simulated ransomware attack state included incorrectly identifying patients on treatment, incorrectly identifying where a patient is in their course of treatment, treating the incorrect patient, and incorrectly tracking delivered fractions. CONCLUSIONS The presented study quantifies the increased risk of incidents when treating in a ransomware attack state, identifies key failure modes that should be prioritized when preparing for a ransomware attack, and provides data that can be used to guide future ransomware resiliency research.
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Affiliation(s)
- Yevgeniy Vinogradskiy
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia Pennsylvania.
| | - Leah Schubert
- Department of Radiation Oncology, University of Colorado School of Medicine, Aurora, Colorado
| | - Amy Taylor
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia Pennsylvania
| | - Shari Rudoler
- Department of Radiation Oncology, Thomas Jefferson University, Philadelphia Pennsylvania
| | - James Lamb
- Department of Radiation Oncology, University of California Los Angeles, Los Angeles California
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Deufel C, Dodoo C, Kavanaugh J, Finley R, Lang K, Sorenson K, Spreiter S, Brooks J, Moseley D, Ahmed SK, Haddock MG, Ma D, Park SS, Petersen IA, Owen DW, Grams MP. Automated target placement for VMAT lattice radiation therapy: enhancing efficiency and consistency. Phys Med Biol 2024; 69:075010. [PMID: 38422544 DOI: 10.1088/1361-6560/ad2ee8] [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: 09/01/2023] [Accepted: 02/29/2024] [Indexed: 03/02/2024]
Abstract
Objective. An algorithm was developed for automated positioning of lattice points within volumetric modulated arc lattice radiation therapy (VMAT LRT) planning. These points are strategically placed within the gross tumor volume (GTV) to receive high doses, adhering to specific separation rules from adjacent organs at risk (OARs). The study goals included enhancing planning safety, consistency, and efficiency while emulating human performance.Approach. A Monte Carlo-based algorithm was designed to optimize the number and arrangement of lattice points within the GTV while considering placement constraints and objectives. These constraints encompassed minimum spacing between points, distance from OARs, and longitudinal separation along thez-axis. Additionally, the algorithm included an objective to permit, at the user's discretion, solutions with more centrally placed lattice points within the GTV. To validate its effectiveness, the automated approach was compared with manually planned treatments for 24 previous patients. Prior to clinical implementation, a failure mode and effects analysis (FMEA) was conducted to identify potential shortcomings.Main results.The automated program successfully met all placement constraints with an average execution time (over 24 plans) of 0.29 ±0.07 min per lattice point. The average lattice point density (# points per 100 c.c. of GTV) was similar for automated (0.725) compared to manual placement (0.704). The dosimetric differences between the automated and manual plans were minimal, with statistically significant differences in certain metrics like minimum dose (1.9% versus 1.4%), D5% (52.8% versus 49.4%), D95% (7.1% versus 6.2%), and Body-GTV V30% (20.7 c.c. versus 19.7 c.c.).Significance.This study underscores the feasibility of employing a straightforward Monte Carlo-based algorithm to automate the creation of spherical target structures for VMAT LRT planning. The automated method yields similar dose metrics, enhances inter-planner consistency for larger targets, and requires fewer resources and less time compared to manual placement. This approach holds promise for standardizing treatment planning in prospective patient trials and facilitating its adoption across centers seeking to implement VMAT LRT techniques.
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Affiliation(s)
- Christopher Deufel
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Christopher Dodoo
- Department of Quantitative Health Sciences, Mayo Clinic, Scottsdale, AZ 85259, United States of America
| | - James Kavanaugh
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Randi Finley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Karen Lang
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Kasie Sorenson
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sheri Spreiter
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Jamison Brooks
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Douglas Moseley
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Safia K Ahmed
- Department of Radiation Oncology, Mayo Clinic, Scottsdale, AZ 85259, United States of America
| | - Michael G Haddock
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Daniel Ma
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Sean S Park
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Ivy A Petersen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Dawn W Owen
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
| | - Michael P Grams
- Department of Radiation Oncology, Mayo Clinic, Rochester, MN 55905, United States of America
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Wang YF, Price MJ, Elliston CD, Munbodh R, Spina CS, Horowitz DP, Kachnic LA. Enhancing Safety in AI-Driven Cone Beam CT-based Online Adaptive Radiation Therapy: Development and Implementation of an Interdisciplinary Workflow. Adv Radiat Oncol 2024; 9:101399. [PMID: 38292890 PMCID: PMC10823112 DOI: 10.1016/j.adro.2023.101399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/11/2023] [Indexed: 02/01/2024] Open
Abstract
Purpose The emerging online adaptive radiation therapy (OART) treatment strategy based on cone beam computed tomography allows for real-time replanning according to a patient's current anatomy. However, implementing this procedure requires a new approach across the patient's care path and monitoring of the "black box" adaptation process. This study identifies high-risk failure modes (FMs) associated with AI-driven OART and proposes an interdisciplinary workflow to mitigate potential medical errors from highly automated processes, enhance treatment efficiency, and reduce the burden on clinicians. Methods and Materials An interdisciplinary working group was formed to identify safety concerns in each process step using failure mode and effects analysis (FMEA). Based on the FMEA results, the team designed standardized procedures and safety checklists to prevent errors and ensure successful task completion. The Risk Priority Numbers (RPNs) for the top twenty FMs were calculated before and after implementing the proposed workflow to evaluate its effectiveness. Three hundred seventy-four adaptive sessions across 5 treatment sites were performed, and each session was evaluated for treatment safety and FMEA assessment. Results The OART workflow has 4 components, each with 4, 8, 13, and 4 sequentially executed tasks and safety checklists. Site-specific template preparation, which includes disease-specific physician directives and Intelligent Optimization Engine template testing, is one of the new procedures introduced. The interdisciplinary workflow significantly reduced the RPNs of the high-risk FMs, with an average decrease of 110 (maximum reduction of 305.5 and minimum reduction of 27.4). Conclusions This study underscores the importance of addressing high-risk FMs associated with AI-driven OART and emphasizes the significance of safety measures in its implementation. By proposing a structured interdisciplinary workflow and integrated checklists, the study provides valuable insights into ensuring the safe and efficient delivery of OART while facilitating its effective integration into clinical practice.
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Affiliation(s)
- Yi-Fang Wang
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Michael J. Price
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Carl D. Elliston
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Reshma Munbodh
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Catherine S. Spina
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - David P. Horowitz
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
| | - Lisa A. Kachnic
- Department of Radiation Oncology, New York-Presbyterian Columbia University Irving Medical Center
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Fog LS, Webb LK, Barber J, Jennings M, Towns S, Olivera S, Shakeshaft J. ACPSEM position paper: pre-treatment patient specific plan checks and quality assurance in radiation oncology. Phys Eng Sci Med 2024; 47:7-15. [PMID: 38315415 DOI: 10.1007/s13246-023-01367-9] [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: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 02/07/2024]
Abstract
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.
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Affiliation(s)
- Lotte S Fog
- Alfred Health Radiation Oncology, Melbourne, VIC, Australia.
| | | | - Jeffrey Barber
- Sydney West Radiation Oncology Network, Blacktown Hospital, Blacktown, NSW, 2148, Australia
| | - Matthew Jennings
- ICON Cancer Care, Cordelia St, South Brisbane, QLD, 4101, Australia
| | - Sam Towns
- Alfred Health Radiation Oncology, Melbourne, VIC, Australia
| | - Susana Olivera
- ICON Cancer Care, Liz Plummer Cancer Centre, Cairns, QLD, 4870, Australia
| | - John Shakeshaft
- ICON Cancer Care, Gold Coast University Hospital, 1 Hospital Blvd, Southport, QLD, 4215, Australia
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Sethi A, Gros S, Brodin P, Ghavidel B, Chai X, Popovic M, Tomé WA, Trichter S, Yang X, Zhang H, Uhl V. Intraoperative radiation therapy with 50 kV x-rays: A multi-institutional review. J Appl Clin Med Phys 2024; 25:e14272. [PMID: 38279520 DOI: 10.1002/acm2.14272] [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: 09/27/2023] [Revised: 11/16/2023] [Accepted: 01/01/2024] [Indexed: 01/28/2024] Open
Abstract
This report covers clinical implementation of a low kV intraoperative radiation therapy (IORT) program with the INTRABEAM® System (Carl Zeiss Meditec AG, Jena, Germany). Based on collective user experience from eight institutions, we discuss best methods of INTRABEAM quality assurance (QA) tests, commissioning measurements, clinical workflow, treatment planning, and potential avenues for research. The guide provides pertinent background information and clinical justification for IORT. It describes the INTRABEAM system and commissioning measurements along with a TG100 risk management analysis to ensure safety and accuracy of the IORT program. Following safety checks, dosimetry measurements are performed for verification of field flatness and symmetry, x-ray output, and depth dose. Also discussed are dose linearity checks, beam isotropy, ion chamber measurements, calibration protocols, and in-vivo dosimetry with optically stimulated luminescence dosimeters OSLDs, and radiochromic film. Emphasis is placed on the importance of routine QA procedures (daily, monthly, and annual) performed at regular intervals for a successful IORT program. For safe and accurate dose delivery, tests of important components of IORT clinical workflow are emphasized, such as, dose prescription, pre-treatment QA, treatment setup, safety checks, radiation surveys, and independent checks of delivered dose. Challenges associated with in-vivo dose measurements are discussed, along with special treatment procedures and shielding requirements. The importance of treatment planning in IORT is reviewed with reference to a Monte Carlo-based commercial treatment planning system highlighting its main features and limitations. The report concludes with suggested topics for research including CT-based image-guided treatment planning and improved prescription dose accuracy. We hope that this multi-institutional report will serve as a guidance document on the clinical implementation and use of INTRABEAM IORT.
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Affiliation(s)
- Anil Sethi
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Sebastien Gros
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, Illinois, USA
| | - Patrik Brodin
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Beth Ghavidel
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Xuedong Chai
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, California, USA
| | - Marija Popovic
- Department of Medical Physics, McGill University Health Center, Montreal, Quebec, Canada
| | - Wolfgang Axel Tomé
- Department of Radiation Oncology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Samuel Trichter
- Department of Radiation Oncology, Weill Cornell Medical Center, New York-Presbyterian Hospital, New York, New York, USA
| | - Xiaofeng Yang
- Department of Radiation Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia, USA
| | - Hualin Zhang
- Department of Radiation Oncology, University of Southern California, Los Angeles, California, USA
| | - Valery Uhl
- Department of Radiation Oncology, Summit Medical Center, Emeryville, California, USA
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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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George SC, Tolakanahalli R, Aguirre S, Kim TP, Samuel EJJ, Mishra V. A single-institution experience with 177Lu RPT workflow improvements and qualifying the SPECT/CT imaging for dosimetry. Front Oncol 2024; 14:1331266. [PMID: 38469241 PMCID: PMC10925616 DOI: 10.3389/fonc.2024.1331266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/22/2024] [Indexed: 03/13/2024] Open
Abstract
Background and purpose Implementing any radiopharmaceutical therapy (RPT) program requires a comprehensive review of system readiness, appropriate workflows, and training to ensure safe and efficient treatment delivery. A quantitative assessment of the dose delivered to targets and organs at risk (OAR) using RPT is possible by correlating the absorbed doses with the delivered radioactivity. Integrating dosimetry into an established RPT program demands a thorough analysis of the necessary components and system fine-tuning. This study aims to report an optimized workflow for molecular radiation therapy using 177Lu with a primary focus on integrating patient-specific dosimetry into an established radiopharmaceutical program in a radiation oncology setting. Materials and methods We comprehensively reviewed using the Plan-Do-Check-Act (PDCA) cycle, including efficacy and accuracy of delivery and all aspects of radiation safety of the RPT program. The GE Discovery SPECT/CT 670DR™ system was calibrated per MIM protocol for dose calculation on MIM SurePlan™ MRT software. Jaszcak Phantom with 15-20 mCi of 177Lu DOTATATE with 2.5 µM EDTA solution was used, with the main energy window defined as 208 keV ±10% (187.6 to 229.2 keV); the upper scatter energy window was set to 240 keV ±5% (228 to 252 keV), while the lower scatter energy window was 177.8 keV ±5% (168.9 to 186.7 keV). Volumetric quality control tests and adjustments were performed to ensure the correct alignment of the table, NM, and CT gantry on SPECT/CT. A comprehensive end-to-end (E2E) test was performed to ensure workflow, functionality, and quantitative dose accuracy. Results Workflow improvements and checklists are presented after systematically analyzing over 400 administrations of 177Lu-based RPT. Injected activity to each sphere in the NEMA Phantom scan was quantified, and the MIM Sureplan MRT reconstruction images calculated activities within ±12% of the injected activity. Image alignment tests on the SPECT/CT showed a discrepancy of more than the maximum tolerance of 2.2 mm on any individual axis. As a result of servicing the machine and updating the VQC and COR corrections, the hybrid imaging system was adjusted to achieve an accuracy of <1 mm in all directions. Conclusion Workflows and checklists, after analysis of system readiness and adequate training for staff and patients, are presented. Hardware and software components for patient-specific dosimetry are presented with a focus on hybrid image registration and correcting any errors that affect dosimetric quantification calculation. Moreover, this manuscript briefly overviews the necessary quality assurance requirements for converting diagnostic images into dosimetry measurement tools and integrating dosimetry for RPT based on 177Lu.
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Affiliation(s)
- Siju C. George
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
- Department of Physics, School of Advanced Sciences, Vellore Institute of Technology, Vellore, India
| | - Ranjini Tolakanahalli
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
| | - Santiago Aguirre
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
| | - Taehyung Peter Kim
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
| | | | - Vivek Mishra
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health, Miami, FL, United States
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Okamoto H, Wakita A, Tani K, Kito S, Kurooka M, Kodama T, Tohyama N, Fujita Y, Nakamura S, Iijima K, Chiba T, Nakayama H, Murata M, Goka T, Igaki H. Plan complexity metrics for head and neck VMAT competition plans. Med Dosim 2024; 49:244-253. [PMID: 38368182 DOI: 10.1016/j.meddos.2024.01.007] [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: 09/06/2023] [Revised: 12/22/2023] [Accepted: 01/24/2024] [Indexed: 02/19/2024]
Abstract
Previous plan competitions have largely focused on dose metric assessments. However, whether the submitted plans were realistic and reasonable from a quality assurance (QA) perspective remains unclear. This study aimed to investigate the relationship between aperture-based plan complexity metrics (PCM) in volumetric modulated arc therapy (VMAT) competition plans and clinical treatment plans verified through patient-specific QA (PSQA). In addition, the association of PCMs with plan quality was examined. A head and neck (HN) plan competition was held for Japanese institutions from June 2019 to July 2019, in which 210 competition plans were submitted. Dose distribution quality was quantified based on dose-volume histogram (DVH) metrics by calculating the dose distribution plan score (DDPS). Differences in PCMs between the two VMAT treatment plan groups (HN plan competitions held in Japan and clinically accepted HN VMAT plans through PSQA) were investigated. The mean (± standard deviation) DDPS for the 98 HN competition plans was 158.5 ± 20.6 (maximum DDPS: 200). DDPS showed a weak correlation with PCMs with a maximum r of 0.45 for monitor unit (MU); its correlation with some PCMs was "very weak." Significant differences were found in some PCMs between plans with the highest 20% DDPSs and the remaining plans. The clinical VMAT and competition plans revealed similar distributions for some PCMs. Deviations in PCMs for the two groups were comparable, indicating considerable variability among planners regarding planning skills. The plan complexity for HN VMAT competition plans increased for high-quality plans, as shown by the dose distribution. Direct comparison of PCMs between competition plans and clinically accepted plans showed that the submitted HN VMAT competition plans were realistic and reasonable from the QA perspective. This evaluation may provide a set of criteria for evaluating plan quality in plan competitions.
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Affiliation(s)
- Hiroyuki Okamoto
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan.
| | - Akihisa Wakita
- Division of Medical Physics, EuroMediTech Co., LTD., 2-20-4 higashigotanda, shinagawa-ku Tokyo, 141-0022, Japan
| | - Kensuke Tani
- Division of Medical Physics, EuroMediTech Co., LTD., 2-20-4 higashigotanda, shinagawa-ku Tokyo, 141-0022, Japan
| | - Satoshi Kito
- Department of Radiology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, 3-18-22 Honkomagome, Bunkyo-ku Tokyo,113-8677, Japan
| | - Masahiko Kurooka
- Department of Radiation Therapy, Tokyo Medical University Hospital, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Takumi Kodama
- Department of Radiation Oncology, Saitama Cancer Center, 780 Ooazakomuro, Inamachi, Kitaadachi-gun Saitama 362-0806, Japan
| | - Naoki Tohyama
- Division of Medical Physics, Tokyo Bay Makuhari Clinic for Advanced Imaging, Cancer Screening, and High-Precision Radiotherapy, 1-17 Toyosuna, Mihama-ku Chiba, Chiba, 261-0024, Japan
| | - Yukio Fujita
- Department of Radiation Sciences, Komazawa University, 1-23-1, komazawa, setagaya-ku Tokyo, 154-8525, Japan
| | - Satoshi Nakamura
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
| | - Kotaro Iijima
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
| | - Takahito Chiba
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
| | - Hiroki Nakayama
- Radiation Safety and Quality Assurance Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
| | - Miyuki Murata
- Department of Radiological Technology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
| | - Tomonori Goka
- Department of Radiological Technology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
| | - Hiroshi Igaki
- Department of Radiation Oncology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku Tokyo, 104-0045, Japan
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Dragojević I, Hoopes D, Mansy G, Rahn D. Radiation Oncology Peer Review in a Community Setting: The Value of Prospective Review. Med Dosim 2024; 49:239-243. [PMID: 38368183 DOI: 10.1016/j.meddos.2024.01.006] [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: 06/02/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 02/19/2024]
Abstract
Peer review is an important component of any radiation oncology continuous quality improvement program. While limited guidelines exist, there is no consensus about how peer review should be performed, and large variations exist among different institutions. The purpose of this report is to describe our experience with peer review at a busy Radiation Oncology clinic and to evaluate the difference between prospective and retrospective peer review. We also performed a failure modes and effects analysis (FMEA) of the peer review process. Starting in 2015, every peer review session was tracked, including recommended changes to treatment plans. We reviewed the frequency, types and severity of these changes. A team of physicians and physicists conducted an FMEA of the peer review process. Between April 2015 and June 2020, a total of 3,691 patients were peer-reviewed. Out of those, 1,903 were prospective reviews (51.6%). Plans reviewed before treatment were almost 4.5 times more likely to be changed by peer review than those reviewed after the start of treatment (0.9% vs 0.2%). Plan changes after the start of treatment had a higher severity than changes prior to the start of treatment. FMEA identified several critical components of peer review. While there is no national standard for peer review, it is evident that prospective peer review is preferable. There may be a subconscious reluctance to change plans already underway, which could be a barrier to improving plans with the peer review process. Rather than reviewing in a group setting, it would be ideal to individually assign review tasks that are embedded in the clinical flow, assuring prospective review for all patients prior to final physician approval. Individual review rather than group review may be more candid, due to interpersonal concerns about publicly disagreeing with colleagues.
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Affiliation(s)
- Irena Dragojević
- Department of Radiation Medicine & Applied Sciences UC San Diego Health 3855 Health Sciences Drive MC 0843 La Jolla, CA 92093-1503.
| | - David Hoopes
- Department of Radiation Medicine & Applied Sciences UC San Diego Health 3855 Health Sciences Drive MC 0843 La Jolla, CA 92093-1503
| | - Gina Mansy
- Department of Radiation Medicine & Applied Sciences UC San Diego Health 3855 Health Sciences Drive MC 0843 La Jolla, CA 92093-1503
| | - Douglas Rahn
- Department of Radiation Medicine & Applied Sciences UC San Diego Health 3855 Health Sciences Drive MC 0843 La Jolla, CA 92093-1503
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Komakech I, Okello D, Kavuma A, Orem J, Tagoe SNA, Wygoda A. Errors in manual radiotherapy treatment procedures and their evolution in a low resource setting: Uganda's experience. Phys Med 2024; 118:103212. [PMID: 38219559 DOI: 10.1016/j.ejmp.2024.103212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 12/05/2023] [Accepted: 01/04/2024] [Indexed: 01/16/2024] Open
Abstract
PURPOSE In Uganda, two-dimensional (2D) radiotherapy treatments have been in use since the establishment of radiotherapy in 1995. Preliminary investigations of treatment records in November 2019 showed evidence of gaps requiring urgent attention. The purpose of this study was to improve the safety of the treatments. METHODS Records of 1164 patients treated in 1387 courses (1412 sites) on Cobalt-60 units were reviewed todetermine the frequency and dosimetric implications of events that occurred at different stepsof the radiotherapy process. The results were presented and discussed with the differentprofessionals for learning purposes. RESULTS Most common dosimetric eventswere omission of block tray, bolus and couch transmission factors in time calculations, incorrect field sizes and depths, wrong beam weighting, independent calculations and prescription doses contributing 28.6 %, 10.1 %, 6.0 %,11.9 %, 10.1 %, 5.4 %, 4.8 % and 8.9 % to the 168 observed errors. Comparison of the calculated treatment doses with the prescribed doses showed that 88 % of the 1412 sites were treated with radiation doses within an accuracy of ± 5 %. However, an analysis of the evolution along the years demonstrated an improvement from 82.8 % in 2018 to 86.1 % in 2019, and 93.2 % in 2020. Most common procedural events were incomplete setup instructions and missing patient data in the record and verify system of the Co-60 units for 57 % and 60.1 % of the 1164 patients. CONCLUSIONS Opportunities for improvement of safety in the delivery of radiotherapy treatments were identified. Learning from these past errors should raise awareness in the team leading to a safer treatments.
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Affiliation(s)
- Ignatius Komakech
- Radiation Oncology Division, Uganda Cancer Institute, P.O. Box 3935, Kampala, Uganda; Department of Physics, Makerere University, P.O. Box 7062, Kampala, Uganda.
| | - Denis Okello
- Department of Physics, Makerere University, P.O. Box 7062, Kampala, Uganda
| | - Awusi Kavuma
- Radiation Oncology Division, Uganda Cancer Institute, P.O. Box 3935, Kampala, Uganda
| | - Jackson Orem
- Radiation Oncology Division, Uganda Cancer Institute, P.O. Box 3935, Kampala, Uganda
| | - Samuel Nii Adu Tagoe
- Department of Radiation Oncology, National Centre for Radiotherapy and Nuclear Medicine, Korle-Bu Teaching Hospital, Guggisberg Avenue, Korle-Bu, Accra, Ghana; Department of Radiography, School of Biomedical and Allied Health Sciences, University of Ghana, P.O. Box LG 25, Legon, Accra, Ghana
| | - Annette Wygoda
- Medical Technology, Health Information and Research Directorate, Ministry of Health P.O. Box 1176 Jerusalem, Israel
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Fagerstrom JM. Radiation oncology department policy development for patients who may become pregnant. J Appl Clin Med Phys 2024; 25:e14256. [PMID: 38175957 PMCID: PMC10860450 DOI: 10.1002/acm2.14256] [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: 03/22/2023] [Revised: 12/07/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024] Open
Abstract
In the context of radiation oncology, radiation exposure from radiation therapy simulation, image guidance, and radiation therapy procedures can have severe adverse biological effects on a developing embryo or fetus. Patients who may be pregnant are screened for the possibility of pregnancy to prevent unnecessary or excessive exposure of radiation in utero. Some radiation therapy patients for whom a pregnancy test is indicated may elect to decline the test. In addition, some patients who are found upon screening to be pregnant may decide, with their attending radiation oncologist, to continue with treatment. A radiation oncology department policy was developed to provide guidelines regarding screening and consent. The policy was designed to prevent unnecessary exposure to patients who may be pregnant, and to limit dose to the embryo or fetus in patients for whom treatment is medically indicated. The policy is presented as an example for physicists intending to develop or revise their own practice's policy regarding patients who may become pregnant.
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Affiliation(s)
- Jessica M. Fagerstrom
- Department of Radiation OncologyUniversity of WashingtonSeattleWashingtonUSA
- Department of Radiation OncologyKaiser PermanenteSeattleWashingtonUSA
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Liu S, Jones E. Clinical implementation of failure modes and effects analysis for gynecological high-dose-rate brachytherapy. J Contemp Brachytherapy 2024; 16:35-47. [PMID: 38584884 PMCID: PMC10993892 DOI: 10.5114/jcb.2024.136295] [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: 09/25/2023] [Accepted: 02/05/2024] [Indexed: 04/09/2024] Open
Abstract
Purpose To use failure modes and effects analysis (FMEA) to identify failure modes for gynecological high-dose-rate (HDR) brachytherapy pathway and score with severity, occurrence, and detectability. Material and methods A research team was organized to observe gynecological HDR brachytherapy pathway, and draw detailed process map to identify all potential failure modes (FMs). The whole team scored FMs based on three parameters, including occurrence (O), detectability (D), and severity (S), and then multiplied three scores to obtain risk priority number (RPN). All FMs were ranked according to RPNs and/or severity scores, and FMs with the highest RPN scores (> 100) and severity scores (> 8) were selected for in-depth analysis. Fault tree analysis (FTA) was applied to find progenitor causes of high-risk FMs and their propagation path, and determine which steps in the process need to be changed and optimized. Efficiency of each existing preventive methods to detect and stop FMs was analyzed, and proposals to improve quality management (QM) and ensure patient safety were suggested. Results The whole gynecological HDR brachytherapy pathway consisted of 5 sub-processes and 30 specific steps, in which 57 FMs were identified. Twelve high-risk FMs were found, including 7 FMs with RPNs > 100 and 5 FMs with severity scores > 8. For these FMs, 2 were in the insertion stage, 1 in the imaging stage, 4 in the treatment planning stage, and 5 in the final stage of treatment delivery. The most serious of these FMs was the change in organ at risk (OAR) during treatment delivery (RPN = 245.7). The FM that occurred most frequently was the applicator shift during patient transfer. Conclusions Failure modes and effects analysis is a prospective risk-based tool that can identity high-risk steps before failures occur, provide preventive measures to stop their occurrence, and improve quality management system.
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Affiliation(s)
- Siyao Liu
- Department of Medical Engineering, Peking Union Medical College Hospital, Beijing, China
| | - Emma Jones
- Radiotherapy Physics and Engineering, Department of Medical Physics, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Oh K, Gallagher KJ, Hyun M, Schott D, Wisnoskie S, Lei Y, Hendley S, Wong J, Wang S, Graff B, Jenkins C, Rutar F, Ahmed M, McNeur J, Taylor J, Schmidt M, Senadheera L, Smith W, Umstadter D, Lele SM, Dai R, Jianghu (James) D, Yan Y, Su‐min Z. Initial experience with an electron FLASH research extension (FLEX) for the Clinac system. J Appl Clin Med Phys 2024; 25:e14159. [PMID: 37735808 PMCID: PMC10860433 DOI: 10.1002/acm2.14159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/04/2023] [Accepted: 08/21/2023] [Indexed: 09/23/2023] Open
Abstract
PURPOSE Radiotherapy delivered at ultra-high-dose-rates (≥40 Gy/s), that is, FLASH, has the potential to effectively widen the therapeutic window and considerably improve the care of cancer patients. The underlying mechanism of the FLASH effect is not well understood, and commercial systems capable of delivering such dose rates are scarce. The purpose of this study was to perform the initial acceptance and commissioning tests of an electron FLASH research product for preclinical studies. METHODS A linear accelerator (Clinac 23EX) was modified to include a non-clinical FLASH research extension (the Clinac-FLEX system) by Varian, a Siemens Healthineers company (Palo Alto, CA) capable of delivering a 16 MeV electron beam with FLASH and conventional dose rates. The acceptance, commissioning, and dosimetric characterization of the FLEX system was performed using radiochromic film, optically stimulated luminescent dosimeters, and a plane-parallel ionization chamber. A radiation survey was conducted for which the shielding of the pre-existing vault was deemed sufficient. RESULTS The Clinac-FLEX system is capable of delivering a 16 MeV electron FLASH beam of approximately 1 Gy/pulse at isocenter and reached a maximum dose rate >3.8 Gy/pulse near the upper accessory mount on the linac gantry. The percent depth dose curves of the 16 MeV FLASH and conventional modes for the 10 × 10 cm2 applicator agreed within 0.5 mm at a range of 50% of the maximum dose. Their respective profiles agreed well in terms of flatness but deviated for field sizes >10 × 10 cm2 . The output stability of the FLASH system exhibited a dose deviation of <1%. Preliminary cell studies showed that the FLASH dose rate (180 Gy/s) had much less impact on the cell morphology of 76N breast normal cells compared to the non-FLASH dose rate (18 Gy/s), which induced large-size cells. CONCLUSION Our studies characterized the non-clinical Clinac-FLEX system as a viable solution to conduct FLASH research that could substantially increase access to ultra-high-dose-rate capabilities for scientists.
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Affiliation(s)
- Kyuhak Oh
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | | | - Megan Hyun
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Diane Schott
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | | | - Yu Lei
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | | | - Jeffrey Wong
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Shuo Wang
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Brendan Graff
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | | | - Frank Rutar
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Md Ahmed
- Varian Medical SystemsPalo AltoCaliforniaUSA
| | | | | | | | | | - Wendy Smith
- Varian Medical SystemsPalo AltoCaliforniaUSA
| | | | | | - Ran Dai
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | | | - Ying Yan
- University of Nebraska Medical CenterOmahaNebraskaUSA
| | - Zhou Su‐min
- University of Nebraska Medical CenterOmahaNebraskaUSA
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Yorke AA, Williams VM, Elmore S, Alleyne-Mike K, Addison E, Kyeremeh PO, Tagoe SNA, Trauernicht CJ, Lazarus GL, Ford EC. Radiation Therapy Physics Quality Assurance and Management Practices in Low- and Middle-Income Countries: An Initial Pilot Survey in Six Countries and Validation Through a Site Visit. Adv Radiat Oncol 2024; 9:101335. [PMID: 38405318 PMCID: PMC10885564 DOI: 10.1016/j.adro.2023.101335] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 07/31/2023] [Indexed: 02/27/2024] Open
Abstract
Purpose Our purpose was to assess physics quality assurance (QA) practices in less resourced radiation therapy (RT) centers to improve quality of care. Methods and Materials A preliminary study was conducted in 2020 of 13 select RT centers in 6 countries, and in 2021, our team conducted onsite visits to all the RT centers in Ghana, one of the countries from the initial survey. The RT centers included 1 private and 2 public institutions (denoted as Public-1 and Public-2). Follow-up surveys were sent to 17 medical physicists from the site visit. Questions centered on the topics of equipment, institutional practice, physics quality assurance, management, and safety practices. Qualitative and descriptive methods were used for data analysis. Questions regarding operational challenges (machine downtime, patient-related issues, power outages, and staffing) were asked on a 5-point Likert scale. Results The preliminary survey from 2020 had a 92% response rate. One key result showed that for RT centers in lower gross national income per capita countries there was a direct correlation between QA needs and the gross national income per capita of the country. The needs identified included film/array detectors, independent dose calculation software, calibration of ion chambers, diodes, thermoluminiscence diodes (TLDs), phantoms for verification, Treatment Planning System (TPS) test phantoms, imaging test phantoms and film dosimeters, education, and training. For the post survey after the site visit in 2021, we received a 100% response rate. The private and the Public-1 institutions each have computed tomography simulators located in their RT center. The average daily patient external beam workload for each clinic on a linear accelerator was: private = 25, Public-1 = 55, Public-2 = 40. The Co-60 workload was: Public-1 = 45, Public-2 = 25 (there was no Co-60 at the private hospital). Public-1 and -2 lacked the equipment necessary to conform to best practices in Task Group reports (TG) 142 and 198. Public-2 reported significant operational challenges. Notably, Public-1 and -2 have peer review chart rounds, which are attended by clinical oncologists, medical physicists, physicians, and physics trainees. All 17 physicists who responded to the post site visit survey indicated they had a system of documenting, tracking, and trending patient-related safety incidents, but only 1 physicist reported using International Atomic Energy Agency Safety in Radiation Oncology. Conclusions The preliminary study showed a direct correlation between QA needs and the development index of a country, and the follow-up survey examines operational and physics QA practices in the RT clinics in Ghana, one of the initial countries surveyed. This will form the basis of a planned continent-wide survey in Africa intended to spotlight QA practices in low- and middle-income countries, the challenges faced, and lessons learned to help understand the gaps and needs to support local physics QA and management programs. Audits during the site visit show education and training remain the most important needs in operating successful QA programs.
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Affiliation(s)
- Afua A. Yorke
- Department of Radiation Oncology, UW Medicine, Seattle, Washington
| | | | - Shekinah Elmore
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kellie Alleyne-Mike
- Department of Radiation Oncology, Cancer Center of Trinidad and Tobago, St. James Medical Complex, St. James, Trinidad, and Tobago
| | - Eric Addison
- Komfo Anokye Teaching Hospital, Oncology Directorate, Kumasi, Ghana
| | | | - Samuel Nii Adu Tagoe
- University of Ghana and National Center for Radiotherapy and Nuclear Medicine, Korle-Bu Teaching Hospital, Accra, Ghana
| | | | | | - Eric C. Ford
- Department of Radiation Oncology, UW Medicine, Seattle, Washington
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Wong L, Pawlicki T. Facilitating the application of systems-theoretic process analysis in healthcare: Creating control structures using process maps. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2023; 43:2411-2421. [PMID: 36899446 DOI: 10.1111/risa.14126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 01/03/2023] [Accepted: 01/17/2023] [Indexed: 06/18/2023]
Abstract
Systems-theoretic process analysis (STPA) is a prospective safety assessment tool increasingly applied in healthcare. A problem hampering STPA proliferation is the difficulty of modeling systems for analysis by creating control structures. In this work, a method is proposed to use existing process maps-commonly available in healthcare-when creating a control structure. The proposed method entails (1) extract information from the process map, (2) determine the modeling boundary of the control structure, (3) transfer the extracted information to the control structure, (4) add additional information to complete the control structure. Two case studies were conducted: (1) ambulance patient offloading in the emergency department and (2) ischemic stroke care with intravenous thrombolysis. The amount of process map-derived information in the control structures was quantified. On average, 68% of the information in the final control structures was derived from the process map. Additional control actions and feedback were added from nonprocess map sources for management and frontline controllers. Despite the differences between process maps and control structures, much of the information in a process map can be used when creating a control structure. The method enables the creation of a control structure from a process map to be done in a structured fashion.
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Affiliation(s)
- Lawrence Wong
- Department of Radiation Medicine & Applied Sciences, University of California San Diego Health, La Jolla, California, USA
| | - Todd Pawlicki
- Department of Radiation Medicine & Applied Sciences, University of California San Diego Health, La Jolla, California, USA
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