Quality assurance analysis of a large multicenter practice: does increased complexity of intensity-modulated...

Error reduction is an important concern in clinical medicine. Intensity-modulated radiotherapy (IMRT) is an important advancement in radiation oncology that increases the complexity of treatment, potentially increasing the error risk. We studied the frequency and severity of errors in a large multicenter practice to ascertain the impact of quality improvement interventions over time, IMRT, and type of practice.

We analyzed prospective data from three academic and 16 community practice sites with 24,775 courses of radiotherapy (9,210 IMRT courses and 15,565 non-IMRT) between January 2006 and December 2009. All IMRT treatment was performed using one centralized dose planning center for all sites.

We prospectively identified various errors or potential errors in 0.14 % vs. 0.40 % of the IMRT vs. non-IMRT courses (13/9,210 vs. 62/15,565, p = 0.0004) and excluding potential errors: 0.03 % for IMRT vs. 0.21% for non-IMRT. We developed the Clinical Radiotherapy Error Severity Scale (CRESS) to classify error severity from 1 to 10, with 1 to 3 for potential or completely correctable errors, 4 to 5 for dose variations <5%, and 6 to 10 for dose variations >5%. Multivariate analyses of CRESS values, severity >4, and any error (including potential) correlated significantly reduced errors with IMRT (p = 0.0001-0.0024) but found no significant difference between the academic and community practice sites and no change in error frequency over time despite implementation of 39 system-wide policy changes by the centralized quality improvement committee.

Despite the increase in complexity with IMRT compared with conventional radiotherapy, it can be delivered with reduced error frequency.