Rate of radiation therapy events in a large academic institution

The goals of this study were to determine the rate of radiation therapy patient events at a large academic institution and to evaluate temporal trends in this rate using statistical process control tools.

An incident reporting system was used to prospectively collect information on radiation therapy patient events and near misses or good catches, using paper-based reports through December 2010 and an online electronic reporting system from January 2011 onward. Patient events were classified into 3 categories on the basis of their severity. The rate of these events from January 2008 to December 2011 was determined. p charts were used to evaluate trends over time.

There were 188 radiation therapy events in the 4-year period, of which 38 were level I or II (more severe) events and 150 were level III (less severe) events. During this 4-year period, a total of 28,488 new patients were treated, and a total of 618,461 radiation fractions were delivered. The rate of radiation therapy events was 0.66% per patient and 0.03% per radiation fraction. There were 358 near misses and good catches in the 4-year period. The p charts indicated that there were no significant changes in the rate of radiation therapy events over time.

The rate of radiation therapy events was very low and remained stable over a 4-year period. In the absence of a national reporting system, single-institution reports can provide valuable information on radiotherapy patient event rates and can augment quality improvement efforts.