Improving Safety For Patients Receiving Radiotherapy: The Successful Application Of Quality Assurance Initiatives

Purpose/Objective(s)Administration of external beam radiation therapy (RT) is a human endeavor, and occasionally RT is not delivered as directed. We have been prospectively monitoring deviations in treatment delivery, and herein assess the impact of clinical, operational, and logistical factors influencing the frequency of treatment deviations. Specifically we hypothesize that (1) Factors such as time of treatment, departmental patient load, and therapist experience will be associated with different deviation rates, and that (2) New quality assurance (QA) measures/tools (e.g. timeouts and checklists) will decrease the deviation rate.Materials/MethodsAs part of ongoing performance improvement initiatives, we have been prospectively monitoring the number, type, and frequency of deviations in RT delivery. All deviations (e.g. regarding SSD, block, energy, site, modulation, set-up marks, calculation, dose), no matter how minor, were reported by therapy/dosimetry/physics staff. Typically, there are no punitive consequences of such reporting. These deviation data were cataloged, and rates of deviations were related to clinical, operational, and logistic factors. At the same time, our quality assurance measures have evolved in response to changes in clinical practice in an attempt to continuously improve patient safety. The impact of such changes in QA procedures (e.g. dosimetrist/physicist/therapist timeouts, checklists) was assessed. Rates of treatment related deviations over time and in different groups were compared by two-tailed Fisher's exact tests.ResultsOverall, deviations are rare (<0.1%) and were most likely to occur on the patient's first day of treatment vs. other days (0.66% [37/5,616] vs. 0.06% [86/134,763], p < 0.0001). When deviations related to dosimetry calculations and simulation activities are excluded, the rate of deviations was still higher on the first treatment vs. subsequent treatments (0.3% [17/5,596] vs. 0.04% [53/134,730], p < 0.0001). Deviations were more common from 11 a.m. - 1 p.m. vs. other times (0.13% vs. 0.08%, p = 0.03). Deviation rates did not appear to correlate with either the patient load or therapists' experience. Deviation rates declined by ∼70% over time, temporally related to new QA procedures/tools: 0.10% (113/108,243) from 2003-2006, vs. 0.03% (11/32,136) in 2007 (p < 0.0001).ConclusionsThe rate of treatment deviations appears greatest during the first treatment session, and also varies with time of day, perhaps related to staffing issues. Checklists, timeouts, and other QA initiatives/tools dramatically reduce the incidence of treatment deviations. The experience of the therapist staff and patient volumes appear not to impact the deviation rate, perhaps reflecting our staffing with a minimum of 2 therapists on each machine at all times. Purpose/Objective(s)Administration of external beam radiation therapy (RT) is a human endeavor, and occasionally RT is not delivered as directed. We have been prospectively monitoring deviations in treatment delivery, and herein assess the impact of clinical, operational, and logistical factors influencing the frequency of treatment deviations. Specifically we hypothesize that (1) Factors such as time of treatment, departmental patient load, and therapist experience will be associated with different deviation rates, and that (2) New quality assurance (QA) measures/tools (e.g. timeouts and checklists) will decrease the deviation rate. Administration of external beam radiation therapy (RT) is a human endeavor, and occasionally RT is not delivered as directed. We have been prospectively monitoring deviations in treatment delivery, and herein assess the impact of clinical, operational, and logistical factors influencing the frequency of treatment deviations. Specifically we hypothesize that (1) Factors such as time of treatment, departmental patient load, and therapist experience will be associated with different deviation rates, and that (2) New quality assurance (QA) measures/tools (e.g. timeouts and checklists) will decrease the deviation rate. Materials/MethodsAs part of ongoing performance improvement initiatives, we have been prospectively monitoring the number, type, and frequency of deviations in RT delivery. All deviations (e.g. regarding SSD, block, energy, site, modulation, set-up marks, calculation, dose), no matter how minor, were reported by therapy/dosimetry/physics staff. Typically, there are no punitive consequences of such reporting. These deviation data were cataloged, and rates of deviations were related to clinical, operational, and logistic factors. At the same time, our quality assurance measures have evolved in response to changes in clinical practice in an attempt to continuously improve patient safety. The impact of such changes in QA procedures (e.g. dosimetrist/physicist/therapist timeouts, checklists) was assessed. Rates of treatment related deviations over time and in different groups were compared by two-tailed Fisher's exact tests. As part of ongoing performance improvement initiatives, we have been prospectively monitoring the number, type, and frequency of deviations in RT delivery. All deviations (e.g. regarding SSD, block, energy, site, modulation, set-up marks, calculation, dose), no matter how minor, were reported by therapy/dosimetry/physics staff. Typically, there are no punitive consequences of such reporting. These deviation data were cataloged, and rates of deviations were related to clinical, operational, and logistic factors. At the same time, our quality assurance measures have evolved in response to changes in clinical practice in an attempt to continuously improve patient safety. The impact of such changes in QA procedures (e.g. dosimetrist/physicist/therapist timeouts, checklists) was assessed. Rates of treatment related deviations over time and in different groups were compared by two-tailed Fisher's exact tests. ResultsOverall, deviations are rare (<0.1%) and were most likely to occur on the patient's first day of treatment vs. other days (0.66% [37/5,616] vs. 0.06% [86/134,763], p < 0.0001). When deviations related to dosimetry calculations and simulation activities are excluded, the rate of deviations was still higher on the first treatment vs. subsequent treatments (0.3% [17/5,596] vs. 0.04% [53/134,730], p < 0.0001). Deviations were more common from 11 a.m. - 1 p.m. vs. other times (0.13% vs. 0.08%, p = 0.03). Deviation rates did not appear to correlate with either the patient load or therapists' experience. Deviation rates declined by ∼70% over time, temporally related to new QA procedures/tools: 0.10% (113/108,243) from 2003-2006, vs. 0.03% (11/32,136) in 2007 (p < 0.0001). Overall, deviations are rare (<0.1%) and were most likely to occur on the patient's first day of treatment vs. other days (0.66% [37/5,616] vs. 0.06% [86/134,763], p < 0.0001). When deviations related to dosimetry calculations and simulation activities are excluded, the rate of deviations was still higher on the first treatment vs. subsequent treatments (0.3% [17/5,596] vs. 0.04% [53/134,730], p < 0.0001). Deviations were more common from 11 a.m. - 1 p.m. vs. other times (0.13% vs. 0.08%, p = 0.03). Deviation rates did not appear to correlate with either the patient load or therapists' experience. Deviation rates declined by ∼70% over time, temporally related to new QA procedures/tools: 0.10% (113/108,243) from 2003-2006, vs. 0.03% (11/32,136) in 2007 (p < 0.0001). ConclusionsThe rate of treatment deviations appears greatest during the first treatment session, and also varies with time of day, perhaps related to staffing issues. Checklists, timeouts, and other QA initiatives/tools dramatically reduce the incidence of treatment deviations. The experience of the therapist staff and patient volumes appear not to impact the deviation rate, perhaps reflecting our staffing with a minimum of 2 therapists on each machine at all times. The rate of treatment deviations appears greatest during the first treatment session, and also varies with time of day, perhaps related to staffing issues. Checklists, timeouts, and other QA initiatives/tools dramatically reduce the incidence of treatment deviations. The experience of the therapist staff and patient volumes appear not to impact the deviation rate, perhaps reflecting our staffing with a minimum of 2 therapists on each machine at all times.