Aileen R. Killen

The Impact of New Technologies on Radiation Oncology Events and Trends in the Past Decade: An Institutional Experience

PURPOSE To review the type and frequency of patient events from external-beam radiotherapy over a time period sufficiently long to encompass significant technology changes. METHODS AND MATERIALS Ten years of quality assurance records from January 2001 through December 2010 were retrospectively reviewed to determine the frequency of events affecting patient treatment from four radiation oncology process steps: simulation, treatment planning, data entry/transfer, and treatment delivery. Patient events were obtained from manual records and, from May 2007 onward, from an institution-wide database and reporting system. Events were classified according to process step of origination and segregated according to the most frequently observed event types. Events from the institution-wide database were evaluated to determine time trends. RESULTS The overall event rate was 0.93% per course of treatment, with a downward trend over time led by a decrease in treatment delivery events. The frequency of certain event types, particularly in planning and treatment delivery, changed significantly over the course of the study, reflecting technologic and process changes. Treatments involving some form of manual intervention carried an event risk four times higher than those relying heavily on computer-aided design and delivery. CONCLUSIONS Although the overall event rate was low, areas for improvement were identified, including manual calculations and data entry, late-day treatments, and staff overreliance on computer systems. Reducing the incidence of pretreatment events is of particular importance because these were more likely to occur several times before detection and were associated with larger dosimetric impact. Further improvements in quality assurance systems and reporting are imperative, given the advent of electronic charting, increasing reliance on computer systems, and the potentially severe consequences that can arise from mistakes involving complex intensity-modulated or image-guided treatments.

Performance of a Trigger Tool for Identifying Adverse Events in Oncology.

PURPOSE Although patient safety is a priority in oncology, few tools measure adverse events (AEs) beyond treatment-related toxicities. The study objective was to assemble a set of clinical triggers in the medical record and assess the extent to which triggered events identified AEs. METHODS We performed a retrospective cohort study to assess the performance of an oncology medical record screening tool at a comprehensive cancer center. The study cohort included 400 patients age 18 years or older diagnosed with breast (n = 128), colorectal (n = 136), or lung cancer (n = 136), observed as in- and outpatients for up to 1 year. RESULTS We identified 790 triggers, or 1.98 triggers per patient (range, zero to 18 triggers). Three hundred four unique AEs were identified from medical record reviews and existing AE databases. The overall positive predictive value (PPV) of the original tool was 0.40 for total AEs and 0.15 for preventable or mitigable AEs. Examples of high-performing triggers included return to the operating room or interventional radiology within 30 days of surgery (PPV, 0.88 and 0.38 for total and preventable or mitigable AEs, respectively) and elevated blood glucose (> 250 mg/dL; PPV, 0.47 and 0.40 for total and preventable or mitigable AEs, respectively). The final modified tool included 49 triggers, with an overall PPV of 0.48 for total AEs and 0.18 for preventable or mitigable AEs. CONCLUSION A valid medical record screening tool for AEs in oncology could offer a powerful new method for measuring and improving cancer care quality. Future improvements could optimize the tools efficiency and create automated electronic triggers for use in real-time AE detection and mitigation algorithms.

ReCAP: Detection of Potentially Avoidable Harm in Oncology From Patient Medical Records

PURPOSE Widespread consensus exists about the importance of addressing patient safety issues in oncology, yet our understanding of the frequency, spectrum, and preventability of adverse events (AEs) across cancer care is limited. METHODS We developed a screening tool to detect AEs across cancer care settings through medical record review. Members of the study team reviewed the scientific literature and obtained structured input from an external multidisciplinary panel of clinicians by using a modified Delphi process. RESULTS The screening tool comprises 76 triggers-readily identifiable findings to screen for possible AEs that occur during cancer care. Categories of triggers are general care, vital signs, medication related, laboratory tests, other orders, and consultations. CONCLUSION Although additional testing is required to assess its performance characteristics, this tool may offer an efficient mechanism for identifying possibly preventable AEs in oncology and serve as an instrument for quality improvement.

Preventable and mitigable adverse events in cancer care: Measuring risk and harm across the continuum

Patient safety is a critical concern in clinical oncology, but the ability to measure adverse events (AEs) across cancer care is limited by a narrow focus on treatment‐related toxicities. The objective of this study was to assess the nature and extent of AEs among cancer patients across inpatient and outpatient settings.

A Communication Training Program to Encourage Speaking-Up Behavior in Surgical Oncology

&NA; Patient safety in the OR depends on effective communication. We developed and tested a communication training program for surgical oncology staff members to increase communication about patient safety concerns. In phase one, 34 staff members participated in focus groups to identify and rank factors that affect speaking‐up behavior. We compiled ranked items into thematic categories that included role relations and hierarchy, staff rapport, perceived competence, perceived efficacy of speaking up, staff personality, fear of retaliation, institutional regulations, and time pressure. We then developed a communication training program that 42 participants completed during phase two. Participants offered favorable ratings of the usefulness and perceived effect of the training. Participants reported significant improvement in communicating patient safety concerns (t40 = –2.76, P = .009, d = 0.48). Findings offer insight into communication challenges experienced by surgical oncology staff members and suggest that our training demonstrates the potential to improve team communication.

Does Laboratory Testing Decrease During Scheduled Downtime of an Electronic Order Entry System

To the Editor: Reducing overuse of laboratory testing remains a challenge. Recent efforts to reduce overused services have called for active clinician engagement. If clinicians can actively engage in identifying such services a priori, it may help reduce their use and improve patient care. At a New York–based comprehensive cancer center, there was a weekend-long scheduled downtime of the system-wide electronic order entry system to implement upgrades (Friday evening, September 7, 2012, through Monday morning, September 10, 2012). It created a unique natural experiment to assess the impact of added work burden on test ordering. Clinicians received advanced notice. During the downtime, clinicians recorded orders in a workbook and informed a named staff member of urgent orders. Some clinicians informally reported more actively engaging in decision making. The study objective was to assess the extent to which there was active clinician engagement, as reflected by a decrease in test orders, during the downtime. We hypothesized that ordering would decrease significantly because of increased work burden. We conducted a retrospective assessment of inpatient laboratory testing over 7 consecutive weekends surrounding the planned downtime. We included tests for all nonsurgical patients ages 18 years and older who were in the hospital during a study weekend. For each admission, we calculated the number of test orders per hospital day, based on the patient’s total number of orders over the entire stay. We assessed use of all tests, and the top 10 most commonly ordered tests. This study was considered exempt research by the institutional review board of Memorial Sloan Kettering Cancer Center. There were approximately 2200 eligible hospital admissions during the study period, averaging 315 admissions per weekend (range = 277-335). Patient case mix was not significantly different across weekends in terms of cancer type, stage, marital status, age, sex, race, reason for admission, vital status, or length of stay. Over the study period, test orders averaged 6.7 orders per patient per day. We observed no differences between the intervention weekend and the comparison weekends in average or median number of laboratory tests ordered per patient per day. We also did not observe differences when stratifying by type of service or for the top 10 most commonly ordered tests. We did observe increases in orders immediately before and after the downtime. Despite anecdotal reports of active engagement, we did not observe differences in test orders at a summary level during the downtime. Individual behavior changes, including those reported to us, may not have been considerable enough to influence the aggregate. Another possibility is that because the downtime was temporary, it did not trigger changes. We observed increases in orders immediately before and after, which may have compensated for any differences during the downtime. Alternatively, clinicians may have been more actively engaged in decision making, but largely viewed orders as appropriate. In this single-institution study, we observed that temporarily moving from an electronic system to a paper system did not have the expected reduction in orders. A more comprehensive understanding of actively engaging clinicians to help reduce overuse is warranted.