T. Meier

Error rates in clinical radiotherapy.

PURPOSE Error rates in clinical oncology are undergoing increasing scrutiny. The purpose of this study was to understand error frequency, error patterns, underlying causal links, consequences, and possible prevention strategies in clinical radiotherapy. PATIENTS AND METHODS Treatment information, self-reported error documentation, and retrospective analyses of electronic treatment verification transcripts for 1,925 consecutive patients treated with a total of 93,332 individual radiotherapy fields were reviewed and analyzed. RESULTS A total of 59 separate errors that affected 168 individual treatment fields were detected, which yielded a crude radiation delivery error rate of 0.18%. All 59 errors were judged to be level I (negligible chance of adverse medical outcome) with the most common error category being a minor treatment field block misplacement. A comprehensive quality assurance program and an electronic record-and-verify linear accelerator interlock system seem to have prevented the occurrence of many additional errors. However, nine of the 59 errors were directly related to the use of this system and generally involved the transposition of similar numbers within series of treatment coordinate data-sets. Overall, radiotherapy error rates favorably compare with reported error rates for pharmaceutical administration in large tertiary care hospitals. CONCLUSION When modern automated error-minimization methods are used along with nonpunitive error reporting systems, clinical radiotherapy seems to be highly safe. Formal error analysis studies may allow the rational design of prevention strategies that are attuned to the frequency, seriousness, and antecedent causes of many classes of potential radiotherapy errors.

Workflow enhancement (WE) improves safety in radiation oncology: Putting the we and team together

PURPOSE To review the impact of a workflow enhancement (WE) team in reducing treatment errors that reach patients within radiation oncology. METHODS AND MATERIALS It was determined that flaws in our workflow and processes resulted in errors reaching the patient. The process improvement team (PIT) was developed in 2010 to reduce errors and was later modified in 2012 into the current WE team. Workflow issues and solutions were discussed in PIT and WE team meetings. Due to tensions within PIT that resulted in employee dissatisfaction, there was a 6-month hiatus between the end of PIT and initiation of the renamed/redesigned WE team. In addition to the PIT/WE team forms, the department had separate incident forms to document treatment errors reaching the patient. These incident forms are rapidly reviewed and monitored by our departmental and institutional quality and safety groups, reflecting how seriously these forms are treated. The number of these incident forms was compared before and after instituting the WE team. RESULTS When PIT was disbanded, a number of errors seemed to occur in succession, requiring reinstitution and redesign of this team, rebranded the WE team. Interestingly, the number of incident forms per patient visits did not change when comparing 6 months during the PIT, 6 months during the hiatus, and the first 6 months after instituting the WE team (P=.85). However, 6 to 12 months after instituting the WE team, the number of incident forms per patient visits decreased (P=.028). After the WE team, employee satisfaction and commitment to quality increased as demonstrated by Gallup surveys, suggesting a correlation to the WE team. CONCLUSIONS A team focused on addressing workflow and improving processes can reduce the number of errors reaching the patient. Time is necessary before a reduction in errors reaching patients will be seen.

Departmental Workload and Physician Errors in Radiation Oncology

Supplemental digital content is available in the text. Purpose The purpose of this work was to evaluate measures of increased departmental workload in relation to the occurrence of physician-related errors and incidents reaching the patient in radiation oncology. Materials and Methods All data were collected for the year 2013. Errors were defined as forms received by our departmental process improvement team; of these forms, only those relating to physicians were included in the study. Incidents were defined as serious errors reaching the patient requiring appropriate action; these were reported through a separate system. Workload measures included patient volumes and physician schedules and were obtained through departmental records for daily and monthly data. Errors and incidents were analyzed for relation with measures of workload using logistic regression modeling. Results Ten incidents occurred in the year. The number of patients treated per day was a significant factor relating to incidents (P < 0.003). However, the fraction of department physicians off-duty and the ratio of patients to physicians were not found to be significant factors relating to incidents. Ninety-one physician-related errors were identified, and the ratio of patients to physicians (rolling average) was a significant factor relating to errors (P < 0.03). The number of patients and the fraction of physicians off-duty were not significant factors relating to errors. A rapid increase in patient treatment visits may be another factor leading to errors and incidents. All incidents and 58% of errors occurred in months where there was an increase in the average number of fields treated per day from the previous month; 6 of the 10 incidents occurred in August, which had the highest average increase at 26%. Conclusions Increases in departmental workload, especially rapid changes, may lead to higher occurrence of errors and incidents in radiation oncology. When the department is busy, physician errors may be perpetuated owing to an overwhelmed departmental checks system, leading to incidents reaching the patient. Insights into workload and workflow will allow for the development of targeted approaches to preventing errors and incidents.