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

Smith, Sandie; Wallis, Andrew; King, Odette; Moretti, Daniel; Vial, Peter James; Shafiq, Jesmin; Bartoň, Michael; Xing, Aitang; Delaney, Geoff P.

doi:10.1016/j.tipsro.2020.02.001

Cited by 11 publications

(12 citation statements)

References 15 publications

(24 reference statements)

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“…Bissonnette and Medlam 7 found that increases in treatment complexity resulted in increases in documentation errors, which aligns with the findings of the current study. Smith et al 20 also reported on a fifteen-year review of incident data in 2020, reporting similar results to the current study with regards to increases in near misses and errors related to the implementation of new technology. Their study found an increase in near miss events associated with the 20 However, overall, there is a paucity of literature reporting a comparative analysis of radiation incidents in relation to the implementation of new technology and electronic processes plus changes within a large academic department over a greater than a ten-year period.…”

Section: Discussionsupporting

confidence: 87%

“…Smith et al. 20 also reported on a fifteen‐year review of incident data in 2020, reporting similar results to the current study with regards to increases in near misses and errors related to the implementation of new technology. Their study found an increase in near miss events associated with the introduction of image‐guided RT (IGRT) technology.…”

Section: Discussionsupporting

confidence: 87%

“…Smith et al. 20 also reported similar results, showing an increase in reporting which coincided with the establishment of a department‐wide incident review meeting and the promotion of a positive safety culture.…”

Section: Discussionmentioning

confidence: 66%

“…Arnold 12 reinforces this by concluding that errors will reduce through building a focus on prevention and harnessing a learning culture. Smith et al 20 also reported similar results, showing an increase in reporting which coincided with the establishment of a department-wide incident review meeting and the promotion of a positive safety culture.…”

Section: Impact Of An Electronic Environmentmentioning

confidence: 68%

“…Their study found an increase in near miss events associated with the introduction of image‐guided RT (IGRT) technology. 20 However, overall, there is a paucity of literature reporting a comparative analysis of radiation incidents in relation to the implementation of new technology and electronic processes plus changes within a large academic department over a greater than a ten‐year period.…”

Section: Discussionmentioning

confidence: 99%

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Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen‐year period

Cornu

Murray

Brown

et al. 2021

J of Medical Radiation Sci

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Introduction: Advancements in technology and processes are designed to bring improvement. However, this is often achieved in parallel with increases in complexity, simultaneously presenting opportunities for new types of errors. This study aims to contextualise the impact of internal departmental changes upon radiation incidents and near misses recorded. Methods: A timeline of events and a comprehensive incident categorisation system were applied to all radiation incidents and near misses recorded at the Princess Alexandra Hospital Radiation Oncology department from 2003 to 2019, inclusive. Descriptive statistics were performed to identify the type and number of incidents reported during the time period in relation to potential changes within the department, with a focus on the implementation of an electronic environment. Results: Over the seventeen-year period, 157 incidents and 76 near misses were reported. The majority of incidents were classified as 'procedural' (78%), with 'treatment' being both the highest point of error and point of detection (49% and 85%, respectively). The largest number of incidents and near misses were reported in 2018 (n = 39) which was also a year that experienced the largest number of departmental changes (n = 16), including the move to a completely electronic planning process. Conclusions: Changes within the department were followed by an increasing number of reported incidents. Proactive measures should be undertaken prior to the implementation of major changes within the department to aid in the minimisation of incident occurrence.

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Section: Discussionsupporting

confidence: 87%

Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 66%

Section: Impact Of An Electronic Environmentmentioning

confidence: 68%

Section: Discussionmentioning

confidence: 99%

See 3 more Smart Citations

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen‐year period

Cornu

Murray

Brown

et al. 2021

J of Medical Radiation Sci

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Improving the safety of radiotherapy treatment processes via incident‐driven FMEA feedback loops

Kornek,

Lotter,

Szkitsak

et al. 2024

J Applied Clin Med Phys

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BackgroundFailure 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.PurposeA 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.MethodsTwenty‐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.ResultsOver 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.ConclusionsOur 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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Evaluating incident learning systems and safety culture in two radiation oncology departments

Adamson

Beldham‐Collins

Sykes

et al. 2021

J of Medical Radiation Sci

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Introduction Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC. Methods A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs. Results Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no‐blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS. Conclusion An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.

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

Cited by 11 publications

References 15 publications

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen‐year period

Impact of technological and departmental changes on incident rates in radiation oncology over a seventeen‐year period

Improving the safety of radiotherapy treatment processes via incident‐driven FMEA feedback loops

Evaluating incident learning systems and safety culture in two radiation oncology departments

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