Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

Novak, Avrey; Nyflot, Matthew J.; Ermoian, Ralph; Jordan, L.; Sponseller, Patricia A.; Kane, Gabrielle; Ford, Eric; Zeng, Jing

doi:10.1118/1.4944739

Cited by 25 publications

(18 citation statements)

References 24 publications

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“…The literature indicates that the majority of errors originate in the pretreatment process. 12,13 In one study, the authors analyzed 2506 incident reports in a large academic center spanning a 5-year period and found that more than half of the reported clinical incidents originated in the treatment preparation process. 12 Novak et al 13 identified incident origination and detection process steps for near-miss incidents.…”

Section: B Data On Physics Plan/chart Reviewmentioning

confidence: 99%

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

et al. 2020

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Background: While the review of radiotherapy treatment plans and charts by a medical physicist is a key component of safe, high-quality care, very few specific recommendations currently exist for this task. Aims: The goal of TG-275 is to provide practical, evidence-based recommendations on physics plan and chart review for radiation therapy. While this report is aimed mainly at medical physicists, others may benefit including dosimetrists, radiation therapists, physicians and other professionals interested in quality management. Methods: The scope of the report includes photon/electron external beam radiotherapy (EBRT), proton radiotherapy, as well as high-dose rate (HDR) brachytherapy for gynecological applications (currently the highest volume brachytherapy service in most practices). The following review time points are considered: initial review prior to treatment, weekly review, and end-of-treatment review. The Task Group takes a risk-informed approach to developing recommendations. A failure mode and effects analysis was performed to determine the highest-risk aspects of each process. In the case of photon/electron EBRT, a survey of all American Association of Physicists in Medicine (AAPM) members was also conducted to determine current practices. A draft of this report was provided to the full AAPM membership for comment through a 3-week open-comment period, and the report was revised in response to these comments.Results: The highest-risk failure modes included 112 failure modes in photon/electron EBRT initial review, 55 in weekly and end-of-treatment review, 24 for initial review specific to proton therapy, and 48 in HDR brachytherapy. A 103-question survey on current practices was released to all AAPM members who self-reported as working in the radiation oncology field. The response rate was 33%. The survey data and risk data were used to inform recommendations. Discussion: Tables of recommended checks are presented and recommendations for best practice are discussed. Suggestions to software vendors are also provided. Conclusions: TG-275 provides specific recommendations for physics plan and chart review which should enhance the safety and quality of care for patients receiving radiation treatments.

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Section: B Data On Physics Plan/chart Reviewmentioning

confidence: 99%

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

et al. 2020

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“…Error scenarios were drawn from incident learning system (ILS) data both within the department and internationally from the system SAFety in Radiation ONcology (SAFRON). The ILS in the Department of Radiation Oncology at the University of Washington Medical Center was implemented in February 2012 to monitor incidents and near‐miss events and reports related to process improvement . Over the 3‐yr period used for this study (February 2012 to March 2015), a total of 3011 events were reported.…”

Section: Methodsmentioning

confidence: 99%

“…The ILS in the Department of Radiation Oncology at the University of Washington Medical Center was implemented in February 2012 to monitor incidents and nearmiss events and reports related to process improvement. 10,12 Over the 3-yr period used for this study (February 2012 to March 2015), a total of 3011 events were reported. The international voluntary system -SAFRONwas implemented by the International Atomic Energy Agency in 2012 in order to provide an opportunity for radiation oncology institutions to report their own incidents and near-misses and to review other institutions' events and corrective actions.…”

Section: A Selecting Errors For Inclusionmentioning

confidence: 99%

“…Studies have demonstrated that the pretreatment physics plan review is potentially one of the most effective and widely used individual quality control checks in the radiation oncology clinic . The fact that treatment planning has been shown to be the major source of incidents in radiation oncology further underscores the importance of the pretreatment physics plan review. Since, to date, no formal guidance exists on how to perform the pretreatment physics plan review, physicists across different clinics likely differ in the procedures that they use to perform the pretreatment physics plan review.…”

Section: Introductionmentioning

confidence: 99%

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Utilizing simulated errors in radiotherapy plans to quantify the effectiveness of the physics plan review

et al. 2018

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Purpose The review of a radiation therapy plan by a physicist prior to treatment is a standard tool for ensuring the quality of treatments. However, little is known about how well this task is performed in practice. The goal of this study is to present a novel method to measure the effectiveness of physics plan review by introducing simulated errors into computerized “mock” treatment charts and measuring the performance of plan review by physicists. Methods We generated six simulated treatment charts containing multiple errors. To select errors, we compiled a list based on events from a departmental incident learning system and an international incident learning system (SAFRON). Seventeen errors with the highest scores for frequency and severity were included in the simulations included six mock treatment charts. Eight physicists reviewed the simulated charts as they would a normal pretreatment plan review, with each chart being reviewed by at least six physicists. There were 113 data points for evaluation. Observer bias was minimized using a simple error vs hidden error approach, using detectability scores for stratification. The confidence interval for the proportion of errors detected was computed using the Wilson score interval. Results Simulated errors were detected in 67% of reviews [58–75%] (95% confidence interval [CI] in brackets). Of the errors included in the simulated plans, the following error scenarios had the highest detection rates: an incorrect isocenter in DRR (93% [70–99%]), a planned dose different from the prescribed dose (92% [67–99%]) and invalid QA (85% [58–96%]). Errors with low detection rates included incorrect CT dataset (0%, [0–39%]) and incorrect isocenter localization in planning system (38% [18–64%]). Detection rates of errors from simulated charts were compared against observed detection rates of errors from a departmental incident learning system. Conclusions It has been notoriously difficult to quantify error and safety performance in oncology. This study uses a novel technique of simulated errors to quantify performance and suggests that the pretreatment physics plan review identifies some errors with high fidelity while other errors are more challenging to detect. These data will guide future work on standardization and automation. The example process studied here was physics plan review, but this approach of simulated errors may be applied in other contexts as well and may also be useful for training and education purposes.

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“…An event is classified by the step in the departmental workflow in which it originated and by the step in which it was found. 21 These steps, which were derived from the AAPM consensus guidelines, consist of eight broad workflow areas, which can be further separated into 103 individual process steps. 22 The highest percentage of events from the system originated in treatment planning and was found at treatment delivery.…”

Section: Methodsmentioning

confidence: 99%

The effectiveness of pretreatment physics plan review for detecting errors in radiation therapy

et al. 2016

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Pretreatment physics plan review is a key safety measure and can detect a high percentage of errors. However, the majority of errors that potentially could have been detected were not detected in this study, indicating the need to improve the pretreatment physics plan review performance. Suggestions for improvement include the automation of specific physics checks performed during the pretreatment physics plan review and the standardization of the review process.

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Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

Cited by 25 publications

References 24 publications

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

Strategies for effective physics plan and chart review in radiation therapy: Report of AAPM Task Group 275

Utilizing simulated errors in radiotherapy plans to quantify the effectiveness of the physics plan review

The effectiveness of pretreatment physics plan review for detecting errors in radiation therapy

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