Identifying Predictive Factors for Incident Reports in Patients Receiving Radiation Therapy

Elnahal, Shereef M.; Blackford, Amanda L.; Smith, Kevin C.; Souranis, A.N.; Briner, Valerie; McNutt, Todd; DeWeese, Theodore L.; Wright, Jean L.; Terezakis, Stephanie A.

doi:10.1016/j.ijrobp.2015.11.041

Cited by 17 publications

(29 citation statements)

References 16 publications

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“…18 Regarding specific causal factors, this study found that human behaviors and communication frequently contribute to RO errors. This is consistent with other studies, 16,[26][27][28][29][30] but the use of the comprehensive taxonomy in this study reveals additional information about how human behavior and communication contribute to errors in RO. For example, 1 small study analyzed events from the Radiation Oncology Safety Information System database and found skill-based errors (roughly corresponds to "physical slips") contributed to all events, and attention failures (roughly corresponds to "loss of attention") contributed to 13 of 25 adverse and 7 of 7 near-miss events.…”

Section: Discussionsupporting

confidence: 93%

“…With increased reporting into ILS, there have been efforts to develop standardized operational frameworks, metrics, and terminologies to learn from errors in RO, 1,[10][11][12][13][14] and prior works have described many features of errors in radiation therapy, such as where they originate in the RO workflow, 15 which clinical features predict event reporting, 16 and the frequencies at which different RO team members report events. 17,18 Although there is a substantial and growing literature on incident learning in the RO context, few reports specifically focus on causes of errors in RO.…”

Section: Introductionmentioning

confidence: 99%

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Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy

Spraker

Fain

Gopan

et al. 2017

Practical Radiation Oncology

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Section: Discussionsupporting

confidence: 93%

Section: Introductionmentioning

confidence: 99%

Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy

Spraker

Fain

Gopan

et al. 2017

Practical Radiation Oncology

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“…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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“…In terms of anatomical sites, head & neck tumor category exhibited highest percentage of major modifications this is probably related to the higher use of IMRT cases for this site and the anatomical complexity associated with the RT plans. IMRT is known to be associated with more incidental reports [15]. A second contender is breast planning and two main issues contribute to the changes, including nodal irradiation, dose to the heart (for left sided breast cancer patients).…”

Section: Discussionmentioning

confidence: 99%

Enhancing value of quality assurance rounds in improving radiotherapy management: a retrospective analysis from King Hussein Cancer Center in Jordan

et al. 2019

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Purpose The quality assurance (QA) chart rounds are multidisciplinary meetings to review radiation therapy (RT) treatment plans. This study focus on describing the changes in RT management based on QA round reviews in a single institution. Materials and Methods After 9 full years of implementation, a retrospective review of all patients whose charts passed through departmental QA chart rounds from 2007 to 2015. The reviewed cases were presented for RT plan review; subcategorized based on decision in QA rounds into: approved, minor modifications or major modifications. Major modification defined as any substantial change which required patient re-simulation orre-planning prior to commencement of RT. Minor modification included treatment plan changes which didn’t necessarily require RT re-planning. Results Overall 7,149 RT treatment plans for different anatomical sites were reviewed at QA rounds. From these treatment plans, 6,654 (93%) were approved, 144 (2%) required minor modifications, while 351 (5%) required major modifications. Major modification included changes in: selected RT dose (96/351, 27%), target volume definition (127/351, 36%), organs-at-risk contouring (10/351, 3%), dose volume objectives/constraints criteria (90/351, 26%), and intent of treatment (28/351, 8%). The RT plans which required major modification according to the tumor subtype were as follows: head and neck (104/904, 12%), thoracic (12/199, 6%), gastrointestinal (33/687,5%), skin (5/106, 5%), genitourinary (16/359, 4%), breast (104/2387, 4%), central nervous system (36/846, 4%), sarcoma (11/277, 4%), pediatric (7/251, 3%), lymphoma (10/423, 2%), gynecological tumors (2/359, 1%), and others (11/351, 3%). Conclusion Multi-disciplinary standardized QA chart rounds provide a comprehensive and an influential method on RT plans and/ or treatment decisions.

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Identifying Predictive Factors for Incident Reports in Patients Receiving Radiation Therapy

Cited by 17 publications

References 16 publications

Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy

Evaluation of near-miss and adverse events in radiation oncology using a comprehensive causal factor taxonomy

Incident learning in radiation oncology: A review

Enhancing value of quality assurance rounds in improving radiotherapy management: a retrospective analysis from King Hussein Cancer Center in Jordan

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