Patient Safety in Radiation Oncology William R Hendee
- Slides: 41
Patient Safety in Radiation Oncology William R. Hendee, Ph. D Distinguished Professor Radiology, Radiation Oncology, Biophysics, Institute for Health & Society Medical College of Wisconsin Adjunct Professor Electrical Engineering University of Wisconsin. Milwaukee Adjunct Professor of Radiology University of New Mexico Professor of Biomedical Engineering Marquette University Adjunct Professor of Radiology University of Colorado
2010 NYT Articles on Risks of Radiation Therapy n n n Radiation Offers New Cures and Ways to Do Harm – January 2010 As Technology Surges, Radiation Safeguards Lag – January 2010 When Medical Radiation Goes Awry - January 2010 Radiation Errors Reported in Missouri – February 2010 VA is Fined over Errors in Radiation in Philadelphia – March 2010 Stereotactic Radiosurgery Overdoses Harm Patients – December 2010 © WRH (March. , 2011)
Alexandra Jn-Charles, center, with her husband, Rene, and their children, died in 2007.
Endorsers: AAMD, ABRF, ACRO, ASRT, CAPCA, CCPM, COMP, CRCPD, JC, NPSF, PULSE, SROA
Who Was There? n n n n 45% medical physicists 15% administrators 10. 5% radiation oncologists 7% radiation therapists 2. 5% dosimetrists 2. 2% regulators 6. 8% other 11% did not respond to the demographics question © WRH (March. , 2011)
The Process of Radiation Treatment IMAGING IS CENTRAL TO EACH STEP IN THE PROCESS Diagnosis Prescription Following/Evaluation Delivery Simulation Verification Planning © WRH (March. , 2011)
Radiation Therapy is a Complex Process Disease Treated n Technology Employed n Information Flow n Human Interactions n Treatment Evaluation n © WRH (March. , 2011)
It is a Complex Process Consultation Patient Information Treatment R&V Prescription Simulation 5 to 40 Fractions Treatment • Different types of cancer • Different treatment techniques • Several technologies Multi- vs. single-vendor environments Main Hospital QA Different users: • Physicians • Physicists • Therapists • Dosimetrists • IS Staff • Administrative Staff Treatment Plan Technological Innovations: • EPID • k. V localize • CBCT • Other IGRT • Research • Clinical activities Other Sites Analysis: On-line Off-line Paper vs. Paperless A lot of Information Communication CUSTOMIZED
*Fig. 11. 1 from Siochi, Information resources for radiation oncology, Ch. 11 of a forthcoming book: Informatics in Radiation Oncology, G. Starkschall, B. Curran, editors. ←----------------Teach ---------------→ ←------Troubleshoot -------→ Data Flow in RO Treat Test (Process) Technologize
Human Interactions in Radiation Oncology
Errors will occur because: Process is Complex n Technology can Malfunction n Handoff Misunderstandings Occur n Humans Are Involved n © WRH (March. , 2011)
TG 100
Process must be Fault-Tolerant n n n n Responsibilities must be Understood Responsibilities must be Manageable Early Warnings must be Available Must Learn from others Mistakes Corrective Actions must Occur Audits must be Conducted Peer Review must Happen Process should be Accredited © WRH (March. , 2011)
What should we be doing for patient safety? We all have different but overlapping roles in the pursuit of improved safety: • • MDs Physicists RTTs + Dosimetrists Administrators IT Vendors Regulators Benedick A. Fraass, Ph. D
Joel Goldwein MD
What should we be doing for patient safety? We all have different but overlapping roles in the pursuit of improved safety: • • MDs Physicists RTTs + Dosimetrists Administrators IT Vendors Regulators Benedick A. Fraass, Ph. D
Safety Culture n n n n Adhering to a culture of safety is a competency Top down enforcement of safety first Zero tolerance for short cuts All staff empowered to stop a procedure Second checks and timeouts Make sure staff do not operate outside their scope of practice Well documented change of P&P process Expectations for staff Dan Pavord, MS, DABR
In working together, everyone should be: Respected n Supported n Appreciated n -Lucian Leape MD © WRH (March. , 2011)
Safety in Radiation Therapy: Recommendations Return control at point of care n As complexity increases, control should be simplified n Provide improved early warnings n Vendors should address concerns intelligibly n © WRH (March. , 2011)
Safety in Radiation Therapy: Recommendations Billing process must be simplified n Recommend staffing levels (Blue Book rev’d) n Therapist workstation needs human factors engineering n Minimize cognitive clutter n © WRH (March. , 2011)
Therapist: Same issue for MD, dosimetrist, etc UNC Lawrence B. Marks, MD
Simple interface
Safety in Radiation Therapy: Recommendations (cont’d) More FMEA and RCA n International reporting system (SAFRON) n As Safe as Reasonably Achievable (ASARA) n Return control at point of care n © WRH (March. , 2011)
Safety in Radiation Therapy: Recommendations (cont’d) Time outs n Check lists, audits, SOPs n Profession-sponsored user groups n Safety champions n © WRH (March. , 2011)
What can an outside audit do for you? 28% 14% How many of you were in 14 -29% Fail group? From Ibbott et al, IJROBP, 71(1) 29% 25%
Still not convinced?
ASTRO Six Point Action Plan n n n Creation of an anonymous national database for event reporting Enhance and accelerate the ASTRO/ACR Practice Accreditation Program Expand education and training programs to include intensive focus on quality and safety Develop tools for cancer patients to use in discussions with radiation oncologists Accelerate development of the IHE-RO program Advocate for passage of the CARE act © WRH (March. , 2011)
Institute for the Assessment of Medical Devices (IAMD) AAPM/MIR n Technology Assessment n Database Management n Safety in Radiation Therapy n Error Reporting n © WRH (March. , 2011)
National Council for Medical Radiation Safety and Quality n n n Standards for cost-effectiveness, quality, safety Resource of knowledge and expertise Promote creation of national registries Guidelines for design, use and evaluation of devices Stakeholder education © WRH (March. , 2011)
Consequences of Harmful Medical Error – University of Michigan Errors disclosed to patients n Compensation offered when at fault n Decreased new legal claims n Reduced time to claim resolution n Lessened total liability costs n Kachalia et al Annals Int Med 2010
Enhance Communication Require respectful communication n Staff can halt disrespectful communication n Time Out procedure endorsed n Written policies n SRT ACTION ITEMS – D. PAVORD
Improve Information Handoffs n n n Procedures for vacation coverage hand-offs More info in treatment planning notes Planning dosimetrist present at simulation Physicians present at simulation if desired Written policies SRT ACTION ITEMS – D. PAVORD
Reduce Distractions Improve work area ergonomics n Reduce work area traffic n Policies for therapists responsibilities n Limit persons at treatment console n Control interactions with therapists n Written policies n SRT ACTION ITEMS – D. PAVORD
Success Factors n n n Checklists/positive written communication on any change with signed recognition (“how the pilot and copilot communicate”) Inspirational “management by walking around” Abolition of the hierarchical nature of the XRT department (Toyota Production System) Time-outs: Any member of the team can stop the assembly line and physician must be present at new starts “We all learn together” implementation of new technology Peer Review/Plan Review/Dept Review Christopher Rose, MD
The Bottom Line Is: SAFETY IS EVERYONE’S RESPONSIBILITY
- Rocog
- Bogardus radiation oncology billing
- Radiation oncology match
- Ucla radiation oncology westwood
- Usf radiation oncology
- Patient 2 patient
- Radiation safety
- Geoff mason
- Background radiation
- Radiation safety
- Essentials of safe care
- Solutions for patient safety bundles
- Patient safety goals kkm
- National patient safety goals 2012
- Patient safety incident policy
- To err is human to cover up is unforgivable
- National patient safety goals 2016
- Chapter 27 patient safety and quality
- Patient environment and safety
- History of patient safety
- Nj patient safety act
- Patient safety assistant
- Dod patient safety program
- Npsg 2018
- Sue sheridan patient safety
- Patient safety goals - awareness course
- National patient safety goals 2017
- Patient safety solutions
- Ihi care bundles
- Safety incident management system
- 2013 hospital national patient safety goals
- Patient safety goals
- Patient safety and quality care movement
- National patient safety framework
- 2018 national patient safety goals
- Scottish patient safety programme
- Canadian patient safety officer course
- Patient safety evaluation system
- Ahrq patient safety survey
- Safety depth formula in ecdis
- Safety care behavioral safety training
- Process safety vs personal safety