Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

Abstract

By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice.

Failure mode and effects analysis in a paperless radiotherapy department

“…To effectively reduce all levels of risk within radiotherapy, a combination of FMEA and incident report data may be preferable . A combined reactive and proactive surveillance approach showed sustained reductions in failure mode risks over 3 years …”

Making Molehills out of a Mountain: Experience with a New Scheduling Strategy to Diminish Workload Variations in Response to Increased Treatment Demands

“…We are emphasizing the importance of the 48-hour minimum period between scheduling and treatment onset to reduce patient stress and to give them time to prepare, but also to ensure sufficient time for treatment preparation and to reduce the risk of error. In that regard, Kapur and colleagues 22,23 reported an analysis of incident reports and the safety initiatives implemented for prevention. They describe a phenomenon of upstream delays (for example, in contouring) not translating into delay of treatment onset, but instead causing downstream tasks (such as quality assurance and medical record completion and verification) to be executed in a rushed and error-prone fashion.…”

Prospective contouring rounds: A novel, high-impact tool for optimizing quality assurance

“…14,15 Retrospective and prospective studies deploying systems engineering approaches in radiation medicine have indicated a strong coupling between select stages of the treatment planning process and patient safety outcomes. 9 Specifically, the contouring and prescription steps were shown to be among the highest patient-safety risk steps in the planning process. In response, we developed CR to Figure 1 The distribution of contouring rounds scoring during the first 6 months of implementation.…”

“…9 The mechanics of introducing and sustaining CR effectively in our multisite department were simplified substantially by the in-house development and adaptation of this whiteboard. Our whiteboard was developed based on specific design needs by clinicians to serve as an operational platform with electronic links to MOSAIQ and our treatment planning systems.…”