Patient Safety

PV QA 3 - Poster Viewing Q&A 3

TU_27_3076 - Radiation Treatment Incidents Are Significantly Reduced Using Modified Treatment Table Parameters and Daily Overrides Report

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

Radiation Treatment Incidents Are Significantly Reduced Using Modified Treatment Table Parameters and Daily Overrides Report
D. Majkszak; Cleveland Clinic Foundation, Cleveland, OH

Purpose/Objective(s): To demonstrate how safe treatment delivery is improved utilizing high quality procedural standardization in spite of inherent obstacles within our large teaching institution’s radiation oncology department. Diverse treatment vendors, inconsistent indexing and setup instructions, and varying treatment field table tolerances can lead to increased overrides and therapist override fatigue, resulting in radiation incidents.

Materials/Methods: Over the past 5 years, our institution has applied several measures to reduce the amount of incidents, with geographic misses being the most crucial. Our department had utilized three separate vendors for treatment machines, but has recently replaced a majority of machines to one vendor specifically. This has allowed us to standardize our table indexing and setup instructions for daily treatment, as well as automatically move the table to isocenter as a result of new technology. New, stringent, table treatment tolerances have been set into place based specifically on treatment site and frequency of imaging. A dosimetry plan consistency check, which is an in-house built program to ensure treatment beams will properly deliver in the radiation treatment plan, has allowed us to better predict the planned vertical value relative to table sag, among other things. Utilizing a daily overrides email report, an examination of overrides for 2017 in particular shows a significant downward trend.

Overrides 2017

March

April

May

June

July

August

September

October

November

Linac1

60

57

49

61

47

57

51

20

16

Linac2

127

107

30

24

46

35

38

22

3

Linac3

79

66

46

20

43

32

25

12

17

Linac4

44

70

38

39

53

44

53

45

14

Radiosurgery2

106

58

77

78

35

59

43

16

30

Radiosurgery1

0

6

26

41

34

21

38

10

18

Total

416

364

266

263

258

248

248

125

98

Results: Much of the historical data has shown many incidents to be related to overrides, several different treatment machine vendors and inconsistent table tolerances. Over the studied 5 year span, a decrease of nearly 80% in geographic miss incidents relative to overrides and setup has been observed. Analysis of implemented changes with regards to procedural standardization and concise treatment table tolerances has shown a sharp decrease of approximately 75% in overrides over the past year in particular from the span of March through November.

Conclusion: Procedural standardization is crucial to the delivery of safe high quality radiation treatment. Particular attention to the frequency and magnitude of overrides and table parameters prior to treatment leads to an increased awareness of accurate treatment position. As a result, we believe patient safety is improved, and related incidents are prevented.

Author Disclosure: D. Majkszak: None.

Send Email for David Majkszak


Assets

TU_27_3076 - Radiation Treatment Incidents Are Significantly Reduced Using Modified Treatment Table Parameters and Daily Overrides Report



Attendees who have favorited this

Please enter your access key

The asset you are trying to access is locked. Please enter your access key to unlock.

Send Email for Radiation Treatment Incidents Are Significantly Reduced Using Modified Treatment Table Parameters and Daily Overrides Report