J. Antone

Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice.

Comparative dosimetry of volumetric modulated arc therapy and limited-angle static intensity-modulated radiation therapy for early-stage larynx cancer

To compare relative carotid and normal tissue sparing using volumetric-modulated arc therapy (VMAT) or intensity-modulated radiation therapy (IMRT) for early-stage larynx cancer. Seven treatment plans were retrospectively created on 2 commercial treatment planning systems for 11 consecutive patients with T1-2N0 larynx cancer. Conventional plans consisted of opposed-wedged fields. IMRT planning used an anterior 3-field beam arrangement. Two VMAT plans were created, a full 360° arc and an anterior 180° arc. Given planning target volume (PTV) coverage of 95% total volume at 95% of 6300 cGy and maximum spinal cord dose below 2500 cGy, mean carotid artery dose was pushed as low as possible for each plan. Deliverability was assessed by comparing measured and planned planar dose with the gamma (γ) index. Full-arc planning provided the most effective carotid sparing but yielded the highest mean normal tissue dose (where normal tissue was defined as all soft tissue minus PTV). Static IMRT produced next-best carotid sparing with lower normal tissue dose. The anterior half-arc produced the highest carotid artery dose, in some cases comparable with conventional opposed fields. On the whole, carotid sparing was inversely related to normal tissue dose sparing. Mean γ indexes were much less than 1, consistent with accurate delivery of planned treatment. Full-arc VMAT yields greater carotid sparing than half-arc VMAT. Limited-angle IMRT remains a reasonable alternative to full-arc VMAT, given its ability to mediate the competing demands of carotid and normal tissue dose constraints. The respective clinical significance of carotid and normal tissue sparing will require prospective evaluation.

Quantifying physician performance using peer review during prospective contouring rounds.

125 Background: This study presents the results of a physician evaluation system (PES) associated with a novel prospective contouring rounds (CR). Traditional chart rounds in radiation therapy (RT) occur after treatment planning and initiation of therapy. In CR, peer review occurs at a more logical process-point, once the contours and written directive (WD) are completed, but before initiation of treatment planning. We previously reported that CR improved quality of care, with the percentage of timely, errorless cases increasing over time. METHODS Starting 9/12, all patients undergoing RT at a high-volume academic center were reviewed in a daily prospective CR attended by physicians, medical physicists, and therapists. The clinical suitability for RT, contours, prescription, and remainder of the WD were prospectively peer reviewed. PES was implemented in 9/13, with each case receiving a grade (A = no deficiencies, B = minor modifications of PTV,OARs, WD, or a prescription/WD mismatch, and C = incomplete contours, significant contour modifications, prescription changes, or laterality modifications). As were cleared for planning. Bs were cleared for planning once remediated. Cs were re-presented at CR upon remediation. Information was pooled to determine physician performance by assigning a grade point average. RESULTS 1,260 cases from 10 physicians have been reviewed using the PES. 25% of cases (318 patients) required modifications before treatment planning commenced. The breakdown of grades was 70% As, 18% Bs and 12% Cs. The average number of cases reviewed per day was 7. The median number of weekdays between contour completion and CR review was 0.8 days. The median contour grade point average was 3.6 (3.3 - 3.9). CONCLUSIONS Peer review during a prospective CR can be used to develop physician performance metrics. 25% of all cases required modifications before starting treatment planning, and 12% of cases required significant remediation. Using the PES, several metrics can be combined to transparently quantify general physician performance. We intend to develop this PES to improve physician performance, optimize continuing medical education efforts, and integrate its use in PQIs for MOC.