Factors associated with radiation therapy incidents in a large academic institution

Incident learning in radiation oncology: A review

“…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 …”

Identifying Factors and Root Causes Associated With Near-Miss or Safety Incidents in Patients Treated With Radiotherapy: A Case-Control Analysis

“…Many of our findings are similar to what has been previously published regarding the nature of complex treatment characteristics and the fact that they are likely linked to the process and not the actual technologic component of the radiation therapy delivery process. [8][9][10] Virtually all studies have found the complexity of treatment planning and delivery to be associated with an increase in NMSIs, and those that have examined patient-and disease-specific factors have also found head and neck site and larger tumor size (with T stage) to be associated with increased incidents. 10 There are several key differences that distinguish our results from those already published.…”

“…8,10,11,15 Specifically, we also found that suboptimal communication was the most significant root cause of safety incidents reaching the patient, with technical treatment delivery error being associated with a higher severity score; most other studies have either not commented on whether patients were affected and/or to what degree or not analyzed root causes and their relationship with NMSIs. 9,13 Our recommendation is to incorporate more dedicated QA systems for documentation (eg, patient setup standards and standards for radiation therapy prescriptions) and communication (eg, face-to-face timeouts between physician and dosimetrist, supported by standardized checklists), which if properly implemented and used could reduce errors related to technical aspects of treatment planning and delivery.…”

“…Other studies have examined factors such as time of day or whether a delay in plan approval was associated with NMSIs Chang et al 8 found time of day (afternoon) and Walker et al 9 found fewer work days from radiation therapy plan approval to the start of treatment to be associated with NMSIs…”

“…For example, a number of retrospective studies have recognized some associations between factors identifying patients at risk for NMSIs, including treatment characteristics (radiation dose, fractionation scheme, and modality), working conditions (time of day, number of days from plan approval to treatment start, and high number of prescription items), and basic demographic and clinical variables (disease diagnosis and age of patients). [6][7][8][9] Elnahal et al 10 explored patient-, treatment-, and disease-specific factors correlating to NMSIs and compared patients experiencing an NMSI with a cohort of patients who did not experience a safety incident; they found that head and neck sites, larger tumors, and use of IMRT/imageguided IMRT (IGIMRT) increased the risk for incidents. 10 Several other studies have found that technologic improvements can lead to an increased rate of reported incidents, especially during their implementation.…”