Risk factors for radiotherapy incidents and impact of an online electronic reporting system

Chang, David; Cheetham, Lynn; Marvelde, Luc te; Bressel, Mathias; Kron, Tomas; Gill, Suki; Tai, Keen Hun; Ball, David; Rose, William; Silva, Linas; Foroudi, Farshad

doi:10.1016/j.radonc.2014.07.011

Cited by 23 publications

(24 citation statements)

References 23 publications

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“…As in earlier studies, 7,13,[27][28][29][30][31]34 most incidents were reported in the treatment stages. We observed a trend -perhaps not observed as strongly previously -where, over time, increasing rates of incidents were coded with an imagingrelated causative factor.…”

Section: Yearsupporting

confidence: 72%

“…24 Some authors have taken this further, introducing "no fly" safety practices, supported by checklists. 25 Many authors have examined the nature of radiation therapy errors 6,13,18,[26][27][28][29][30][31] and while this is valuable, we are of the opinion that additional value can also potentially be derived from considering the organisation's safety culture. 19,24 Therefore, we have looked broadly at incident reporting and have considered the propensity to report near-miss incidents.…”

Section: Discussionmentioning

confidence: 99%

“…33 The rates of radiation therapy related incidents reported here compare favourably with previous studies (Table 2). Chang et al 28 reported a rate of 2.64 incidents per 100 courses over a 10-year period from 2001 to 2011. Interestingly, the rate of incidents increased with the implementation of an electronic reporting system, implying perhaps that fewer incidents went unreported.…”

Section: Discussionmentioning

confidence: 99%

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Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Greenham

Manley

Turnbull

et al. 2018

Reports of Practical Oncology & Radiotherapy

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The application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.

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Section: Yearsupporting

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Greenham

Manley

Turnbull

et al. 2018

Reports of Practical Oncology & Radiotherapy

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show abstract

“…It is, in short, a culture dedicated to improvement. Reports have appeared in the radiation oncology literature documenting a shift in culture and have linked it to incident learning, and several RT studies have explicitly noted the importance of just culture . According to the AHRQ, a culture of safety has four main features: knowledge that an organization is engaged in high‐risk activities, with the determination to maintain safe operations; a blame‐free environment where individuals can report errors or near misses without punishment; collaboration across disciplines and titles to seek innovative patient safety solutions; and the unfailing commitment of the organization to address safety issues .…”

Section: A Systems View Of Errormentioning

confidence: 99%

“…In the late 1990s, reports began to appear of institutional experience with incident learning . This literature has continued to grow, and as of 2017, there are over 50 studies in the radiation oncology literature about ILS or using ILS data …”

Section: Introductionmentioning

confidence: 99%

Incident learning in radiation oncology: A review

Ford

Evans

2018

Medical Physics

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Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning. Core principles of patient safety in the context of ILS are discussed, including the systems view of error, culture of safety, and contributing factors such as cognitive bias. Finally, the topics of medical error disclosure and second victim syndrome are discussed. In spite of the rapid progress and understanding of ILS, challenges remain in applying ILS to the radiation oncology context. This comprehensive review may serve as a springboard for further work.

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Using a daily monitoring system to reduce treatment position override rates in external beam radiation therapy

Magnelli

LaHurd

et al. 2022

J Applied Clin Med Phys

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Purpose/objectives: To report our 7‐year experience with a daily monitoring system to significantly reduce couch position overrides and errors in patient treatment positioning. Materials and methods: Treatment couch position override data were extracted from a radiation oncology–specific electronic medical record system from 2012 to 2018. During this period, we took several actions to reduce couch position overrides, including reducing the number of tolerance tables from 18 to 6, tightening tolerance limits, enforcing time outs, documenting reasons for overrides, and timely reviewing of overrides made from previous treatment day. The tolerance tables included treatment categories for head and neck (HN) (with/without cone beam CT [CBCT]), body (with/without CBCT), stereotactic body radiotherapy (SBRT), and clinical setup for electron beams. For the same time period, we also reported treatment positioning–related incidents that were recorded in our departmental incident report system. To verify our tolerance limits, we further examined couch shifts after daily kilovoltage CBCT (kV‐CBCT) for the patients treated from 2018 to 2021. Results: From 2012 to 2018, the override rate decreased from 11.2% to 1.6%/year, whereas the number of fractions treated in the department increased by 23%. The annual patient positioning error rate was also reduced from 0.019% in 2012, to 0.004% in 2017 and 0% in 2018. For patients treated under daily kV‐CBCT guidance from 2018 to 2021, the applied couch shifts after imaging registration that exceeded the tolerance limits were low, <1% for HN, <1.2% for body, and <2.6% for SBRT. Conclusions: The daily monitoring system, which enables a timely review of overrides, significantly reduced the number of treatment couch position overrides and ultimately resulted in a decrease in treatment positioning errors. For patients treated with daily kV‐CBCT guidance, couch position shifts after CBCT image guidance demonstrated a low rate of exceeding the set tolerance.

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Risk factors for radiotherapy incidents and impact of an online electronic reporting system

Cited by 23 publications

References 23 publications

Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Incident learning in radiation oncology: A review

Using a daily monitoring system to reduce treatment position override rates in external beam radiation therapy

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