Patient Safety

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TU_27_3073 - Incident Patterns in an Integrated Radiation Oncology Network: Implications of Centralized Quality Review

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Incident Patterns in an Integrated Radiation Oncology Network: Implications of Centralized Quality Review
B. S. Gill1, J. Sinicki1, M. S. Huq1, G. Bednarz1, S. Beriwal1, D. D'Ambrosio2, and D. E. Heron1; 1UPMC Hillman Cancer Center, Pittsburgh, PA, 2New Jersey Cyberknife, Toms River, NJ

Purpose/Objective(s): Amidst an institutional network of 24 facilities, the Quality Oversight Committee (QOC) was founded in 2008 to provide centralized review of radiation oncology incidents (ROIs) and facilitate network-wide implementation of corrective and preventative measures. Data was analyzed to identify ROI patterns and the impact of the QOC.

Materials/Methods: An online reporting tool was self-formulated in 2012, providing access to all staff members as an opportunity to report ROIs. Captured ROIs were classified as events (ROEs), where an incident with consequences occurred, or near misses (NMs). ROIs captured exclude those from internal physician peer review. All ROIs were discussed at monthly QOC meetings with formulation of an appropriate plan of action with involved parties and peers. Data recorded included the Clinical Radiation therapy Error Severity Scale (CRESS); TG-100 severity score; involved staff; and treatment fraction, intent, site and technique. Incident reports, meeting minutes and chart reviews were reviewed here. ROIs were categorized by fiscal year (July to June).

Results: From fiscal year (FY) 2013 through 2017, a total of 125 ROIs occurred with 87 (69.6%) ROEs of which 11 (8.8%) were state reportable. Median CRESS scores and TG-100 scores for ROEs were 4 (range 1-7) and 3 (range 1-8), respectively, with 32.8% of all ROIs resulting in plan/directive changes. Many ROIs involved therapists (67.2%), particularly among ROEs (85.1%). While 78 ROEs (89.7%) were discovered during the treatment course, 60.9% occurred within the first week. Of NMs, 21 (55.3%) were discovered prior to treatment, 10 (47.6%) during chart checks and 8 (38.1%) at confirmatory simulation. The most common types of ROIs were related to setup errors (37.6%), inadequate documentation (32.8%) and planning issues (23.2%). NMs were largely related to documentation (50%) while most ROEs were attributed to setup errors (40.2%). Among 35 setup ROEs, the most common issues were from incorrect SSDs, often in the setting of extended field treatment, and improper isocenter shifts. The most common corrective measures among all ROIs involved in-service with staff and review of policies (77.6%), alteration of policies/procedures (29.6%), and/or documentation/EMR process changes (7.2%). With implementation of the QOC, over time, there was a reduction in the number of ROEs: 21 (24%) in 2013, 26 (30%) in 2014, 15 (17%) in 2015, 16 (18%) in 2016, and 9 (10%) in 2017. Excluding FY2013, the mean time to submitting ROIs for review decreased over time: 2.6 days in 2013, 6.3 in 2014, 4.3 in 2015, 3.0 in 2016 and 2.3 in 2017.

Conclusion: Common issues that result in ROIs include documentation and set up errors, particularly those associated with extended SSD or isocenter shifts. Use of prospective measures such as chart checks and confirmatory simulation, while not error-proof, may reduce occurrence of ROIs. Development of a centralized committee has promoted more rapid communication of ROIs and reduction in actual events over time.

Author Disclosure: B.S. Gill: None. J. Sinicki: None. M. Huq: Honoraria; Varian Medical Systems. Chair, Therapy Physics Committee (TPC); AAPM. Vice chair, Science Council; American Association of Physicists in Medicine. D. D'Ambrosio: None. D.E. Heron: No personal compensation; Accuray Exchange in Radiation Oncology. Partnership; Cancer Treatment Services International. Vice Chairman of Clinical Affairs; University of Pittsburgh School of Medicine. Director of Radiation Services; UPMC CancerCenter.

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