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Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety
Gary Ezzell1, Bhisham Chera2, Adam Dicker3
1Department of Radiation Oncology, Mayo Clinic Arizona, Phoenix, Arizona.
Practical Radiation Oncology
|January 14, 2018
Summary
Radiation oncology errors often stem from problematic treatment plans and incorrect instructions, leading to flawed treatments. Analyzing incident reports reveals common error pathways needing intervention to improve patient safety.
Area of Science:
- Medical Physics
- Radiation Oncology
- Patient Safety
Background:
- The Radiation Oncology Incident Learning System (RO-ILS) collects event reports from various facilities.
- Understanding error pathways is crucial for improving radiation oncology safety and treatment delivery.
Purpose of the Study:
- To extract and analyze common error pathways from RO-ILS data.
- To identify opportunities for preventing errors and mitigating their impact on patient treatment.
Main Methods:
- Reviewed 2344 event reports submitted to RO-ILS.
- Focused on 396 high-priority reports, assigning keywords to classify events.
- Developed fault trees to visualize error pathways leading to three general error types.
Main Results:
- Identified 173 events (44%) fitting into three main error categories: problematic plans, incorrect therapist instructions, or wrong treatment delivery.
- Physician error in prescribing treatment plans accounted for 65% of "problematic plan" errors.
- 44% of these events resulted in incorrectly delivered radiation therapy.
Conclusions:
- Common error pathways exist in radiation oncology, extending to treatment delivery.
- Further research and collaboration are needed to develop and share best practices for error prevention and mitigation.
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