Radiation Oncology Safety Information System (ROSIS) – Profiles of participants and the first 1074 incident reports

Cunningham, Joanne; Coffey, Mary; Knöös, Tommy; Holmberg, Ola

doi:10.1016/j.radonc.2010.10.023

Cited by 85 publications

(56 citation statements)

References 41 publications

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“…In radiation oncology, cross-organizational and international voluntary reporting systems have been used to share incident information [25,26], and incident learning systems have been used successfully to improve patient safety at several institutions [15,16,21]. In our department, the MDT meeting, as a structure on the clinical side, had been empowered to improve patient safety with the internal incident learning since 2009, and the integrated clinical staff act as facilitators of quality in clinical practice presently.…”

Section: Discussionmentioning

confidence: 99%

Quality Improvement in External Radiation Therapy Using a Departmental Incident Reporting System and Multidisciplinary Team Efforts

Monzen¹,

Yoshioka²

2015

J Nucl Med Radiat Ther

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Purpose: Incidents in radiation therapy occur due to the complex process, non-automated procedures, and miscommunication. We performed a prospective study to reduce the incidence rate during 4 years of external radiation therapy using incident-reporting system with multidisciplinary team (MDT) efforts. Methods:Incidents from May 2009 to April 2013 were recorded, blame-free and voluntarily. The incidents involved errors which were unintended, whether they caused patient harm or not. Cause analysis of the incidents and interventions were performed through an MDT meeting in which all staff participated, including radiation oncologists, medical physicists, nurses, and radiation technologists. Our interventions included continuous feedback and improvements with minimized unnecessary stress. Results:In total, 49 actual incidents among 2,350 radiation therapy courses were noted during the 4 years. The actual incidents occurred most frequently during treatment planning (74%, 36/49), followed by treatment delivery (20%, 10/49). Of the 49 actual incidents, 59%, 16%, 12%, 8%, 2%, 2% incidents were caused by failure to follow procedures or policies, incomplete knowledge, miscommunication, operation errors, work environment, and incorrect supervision, respectively. The actual incident rates, based on the number of treatment courses, were 4%, 2%, 1%, and 1% in the first, second, third, and fourth years, respectively. We found a significant decrease in the actual incident rate during the third and fourth years compared with the first year (p<0.01). Conclusions:The frequency of incidents during radiation therapy was reduced using a voluntary incident reporting system and the efforts of a MDT.

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Section: Discussionmentioning

confidence: 99%

Quality Improvement in External Radiation Therapy Using a Departmental Incident Reporting System and Multidisciplinary Team Efforts

Monzen¹,

Yoshioka²

2015

J Nucl Med Radiat Ther

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“…2,9,35] shows that the treatment process itself, e.g. procedures, is in most cases the main cause of accidents; while nowadays technology is more and more inherent safe.…”

Section: Set Up Of the Reportmentioning

confidence: 99%

NCS Report 25: Process management and quality assurance for intracranial stereotactic treatment

Heukelom¹,

Hoffmans-Holtzer²,

Marijnissen³

et al. 2015

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“…The types of errors during BT treatments and their occurrence rates are not well known. Existing channels of information regarding errors during RT include dedicated databases [6][7][8][9] and published reports. [1][2][3]10 However, since RT clinics are not necessarily subject to policies that require public reporting in case of detected treatment errors, it is likely that a substantial portion of occurred incidences are left unknown to the RT community.…”

Section: Treatment Errors In Btmentioning

confidence: 99%

In vivodosimetry: trends and prospects for brachytherapy

Kertzscher¹,

Rosenfeld²,

Beddar³

et al. 2014

BJR

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The error types during brachytherapy (BT) treatments and their occurrence rates are not well known. The limited knowledge is partly attributed to the lack of independent verification systems of the treatment progression in the clinical workflow routine. Within the field of in vivo dosimetry (IVD), it is established that real-time IVD can provide efficient error detection and treatment verification. However, it is also recognized that widespread implementations are hampered by the lack of available high-accuracy IVD systems that are straightforward for the clinical staff to use. This article highlights the capabilities of the state-of-the-art IVD technology in the context of error detection and quality assurance (QA) and discusses related prospects of the latest developments within the field. The article emphasizes the main challenges responsible for the limited practice of IVD and provides descriptions on how they can be overcome. Finally, the article suggests a framework for collaborations between BT clinics that implemented IVD on a routine basis and postulates that such collaborations could improve BT QA measures and the knowledge about BT error types and their occurrence rates.

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Radiation Oncology Safety Information System (ROSIS) – Profiles of participants and the first 1074 incident reports

Cited by 85 publications

References 41 publications

Quality Improvement in External Radiation Therapy Using a Departmental Incident Reporting System and Multidisciplinary Team Efforts

Quality Improvement in External Radiation Therapy Using a Departmental Incident Reporting System and Multidisciplinary Team Efforts

NCS Report 25: Process management and quality assurance for intracranial stereotactic treatment

In vivodosimetry: trends and prospects for brachytherapy

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