Camille E Noel1, Veerarajesh Gutti2, Walter Bosch1, Sasa Mutic1, Eric Ford3, Stephanie Terezakis4, Lakshmi Santanam5. 1. Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri. 2. Department of Radiation Oncology, Scott and White Healthcare, Temple, Texas. 3. Department of Radiation Oncology, University of Washington Medical Center, Seattle, Washington. 4. Department of Radiation Oncology, Johns Hopkins University, Baltimore, Maryland. 5. Department of Radiation Oncology, Washington University School of Medicine, St. Louis, Missouri. Electronic address: lsantanam@radonc.wustl.edu.
Abstract
PURPOSE: To quantify the potential impact of the Integrating the Healthcare Enterprise-Radiation Oncology Quality Assurance with Plan Veto (QAPV) on patient safety of external beam radiation therapy (RT) operations. METHODS AND MATERIALS: An institutional database of events (errors and near-misses) was used to evaluate the ability of QAPV to prevent clinically observed events. We analyzed reported events that were related to Digital Imaging and Communications in Medicine RT plan parameter inconsistencies between the intended treatment (on the treatment planning system) and the delivered treatment (on the treatment machine). Critical Digital Imaging and Communications in Medicine RT plan parameters were identified. Each event was scored for importance using the Failure Mode and Effects Analysis methodology. Potential error occurrence (frequency) was derived according to the collected event data, along with the potential event severity, and the probability of detection with and without the theoretical implementation of the QAPV plan comparison check. Failure Mode and Effects Analysis Risk Priority Numbers (RPNs) with and without QAPV were compared to quantify the potential benefit of clinical implementation of QAPV. RESULTS: The implementation of QAPV could reduce the RPN values for 15 of 22 (71%) of evaluated parameters, with an overall average reduction in RPN of 68 (range, 0-216). For the 6 high-risk parameters (>200), the average reduction in RPN value was 163 (range, 108-216). The RPN value reduction for the intermediate-risk (200 > RPN > 100) parameters was (0-140). With QAPV, the largest RPN value for "Beam Meterset" was reduced from 324 to 108. The maximum reduction in RPN value was for Beam Meterset (216, 66.7%), whereas the maximum percentage reduction was for Cumulative Meterset Weight (80, 88.9%). CONCLUSION: This analysis quantifies the value of the Integrating the Healthcare Enterprise-Radiation Oncology QAPV implementation in clinical workflow. We demonstrate that although QAPV does not provide a comprehensive solution for error prevention in RT, it can have a significant impact on a subset of the most severe clinically observed events.
PURPOSE: To quantify the potential impact of the Integrating the Healthcare Enterprise-Radiation Oncology Quality Assurance with Plan Veto (QAPV) on patient safety of external beam radiation therapy (RT) operations. METHODS AND MATERIALS: An institutional database of events (errors and near-misses) was used to evaluate the ability of QAPV to prevent clinically observed events. We analyzed reported events that were related to Digital Imaging and Communications in Medicine RT plan parameter inconsistencies between the intended treatment (on the treatment planning system) and the delivered treatment (on the treatment machine). Critical Digital Imaging and Communications in Medicine RT plan parameters were identified. Each event was scored for importance using the Failure Mode and Effects Analysis methodology. Potential error occurrence (frequency) was derived according to the collected event data, along with the potential event severity, and the probability of detection with and without the theoretical implementation of the QAPV plan comparison check. Failure Mode and Effects Analysis Risk Priority Numbers (RPNs) with and without QAPV were compared to quantify the potential benefit of clinical implementation of QAPV. RESULTS: The implementation of QAPV could reduce the RPN values for 15 of 22 (71%) of evaluated parameters, with an overall average reduction in RPN of 68 (range, 0-216). For the 6 high-risk parameters (>200), the average reduction in RPN value was 163 (range, 108-216). The RPN value reduction for the intermediate-risk (200 > RPN > 100) parameters was (0-140). With QAPV, the largest RPN value for "Beam Meterset" was reduced from 324 to 108. The maximum reduction in RPN value was for Beam Meterset (216, 66.7%), whereas the maximum percentage reduction was for Cumulative Meterset Weight (80, 88.9%). CONCLUSION: This analysis quantifies the value of the Integrating the Healthcare Enterprise-Radiation Oncology QAPV implementation in clinical workflow. We demonstrate that although QAPV does not provide a comprehensive solution for error prevention in RT, it can have a significant impact on a subset of the most severe clinically observed events.
Authors: Scott W Hadley; Marc L Kessler; Dale W Litzenberg; Choonik Lee; Jim Irrer; Xiaoping Chen; Eduardo Acosta; Grant Weyburne; Wayne Keranen; Kwok Lam; Elizabeth Covington; Kelly C Younge; Martha M Matuszak; Jean M Moran Journal: J Appl Clin Med Phys Date: 2016-01-08 Impact factor: 2.102