Incident learning in radiation oncology: A review

Ford, Eric; Evans, Suzanne B.

doi:10.1002/mp.12800

Cited by 55 publications

(56 citation statements)

References 141 publications

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“…Incident learning systems have been proven to be a valuable source of information and should be used for process improvement. 48 The tracking of incidents during the initial plan check is strongly encouraged to facilitate improvement in both the planning process and the plan check process.…”

Section: A1 Practice Recommendations For Photon/ Electron Ebrt Inmentioning

confidence: 99%

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

et al. 2020

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Background: While the review of radiotherapy treatment plans and charts by a medical physicist is a key component of safe, high-quality care, very few specific recommendations currently exist for this task. Aims: The goal of TG-275 is to provide practical, evidence-based recommendations on physics plan and chart review for radiation therapy. While this report is aimed mainly at medical physicists, others may benefit including dosimetrists, radiation therapists, physicians and other professionals interested in quality management. Methods: The scope of the report includes photon/electron external beam radiotherapy (EBRT), proton radiotherapy, as well as high-dose rate (HDR) brachytherapy for gynecological applications (currently the highest volume brachytherapy service in most practices). The following review time points are considered: initial review prior to treatment, weekly review, and end-of-treatment review. The Task Group takes a risk-informed approach to developing recommendations. A failure mode and effects analysis was performed to determine the highest-risk aspects of each process. In the case of photon/electron EBRT, a survey of all American Association of Physicists in Medicine (AAPM) members was also conducted to determine current practices. A draft of this report was provided to the full AAPM membership for comment through a 3-week open-comment period, and the report was revised in response to these comments.Results: The highest-risk failure modes included 112 failure modes in photon/electron EBRT initial review, 55 in weekly and end-of-treatment review, 24 for initial review specific to proton therapy, and 48 in HDR brachytherapy. A 103-question survey on current practices was released to all AAPM members who self-reported as working in the radiation oncology field. The response rate was 33%. The survey data and risk data were used to inform recommendations. Discussion: Tables of recommended checks are presented and recommendations for best practice are discussed. Suggestions to software vendors are also provided. Conclusions: TG-275 provides specific recommendations for physics plan and chart review which should enhance the safety and quality of care for patients receiving radiation treatments.

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Section: A1 Practice Recommendations For Photon/ Electron Ebrt Inmentioning

confidence: 99%

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

et al. 2020

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“…ILS have been implemented in many organisations globally to improve safety in RO delivery. The development and use of ILS is supported by professional society recommendations, industry regulations, accreditation and objective evidence [8]. These include ASTRO's ''Target Safely" campaign [9], The European society for radiotherapy and oncology's (ESTRO) Radiation Oncology Safety Education Information System (ROSEIS) [10], a voluntary web based reporting system designed for individual clinic use as well as facilitating information exchange between clinics.…”

Section: Introductionmentioning

confidence: 99%

“…The ILS performance was analysed over an initial three year study period (2004)(2005)(2006)(2007) and the results indicated a reduction in error rate, both near miss and actual error [17]. However, determining whether the system specifically improves safety remains uncertain since reporting rates are influenced by other variables such as the introduction of new technology and changes in reporting culture [8].…”

Section: Introductionmentioning

confidence: 99%

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

Smith

Wallis

King

et al. 2020

Technical Innovations & Patient Support in Radiation Oncolo

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

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“…Such a system can require substantial effort. 7 However, the bulk of this effort need not be shouldered by the medical physicist nor, arguably, should it be. The effort should be distributed amongst many professional staff and trainees.…”

Section: B | Resources and Structurementioning

confidence: 99%

Parallel perspectives for building sustainable safety initiatives

Ford

Moran

Kim

et al. 2019

J Applied Clin Med Phys

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Safety improvement is just that, a continuous improvement toward safer and higher quality operations. As such, it is not a destination that one will reach, after which no further effort is needed. Rather it is a continuous process that must go on as long as patients are to be treated. Viewed this way, the most important aspect of a safety and quality program is the long-term investments toward sustainability. What are the programmatic initiatives and actions that can be taken now to foster a successful program for years to come? The role of medical physicist in quality and safety for clinical environment and its impact on the medical physics profession has been fiercely discussed in the previous editorials. 1,2 This article includes perspectives from four thought-leaders on achieving sustainable programs in safety and quality considering resources, leadership, sharing ownership and participating in quality improvement (QI) efforts, integrating with daily work, selecting a focus for projects, and celebrating wins as a team.

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Incident learning in radiation oncology: A review

Cited by 55 publications

References 141 publications

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

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

Parallel perspectives for building sustainable safety initiatives

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