Chasing Zero Harm in Radiation Oncology: Using Pre-treatment Peer Review

Area of Science:

• Radiation Oncology
• Medical Physics
• Quality Improvement

Background:

• The Joint Commission promotes High Reliability Organizations (HROs) to "Chase Zero Harm" in patient care.
• Quality checks in radiation oncology must occur pre-treatment to prevent errors, not just mitigate them.
• Peer review prior to treatment initiation is crucial for achieving "zero harm" in radiation oncology.

Purpose of the Study:

• To implement and evaluate a multidisciplinary group consensus peer review (GCPR) model for radiation oncology treatment plans.
• To assess the effectiveness of pre-treatment peer review in preventing patient harm.
• To "chase zero harm" by identifying and correcting errors before treatment delivery.

Main Methods:

• A Group Consensus Peer Review (GCPR) model involving physicians, residents, physicists, and dosimetrists was utilized.
• Complex cases underwent treatment planning conferences reviewing target volumes, dose coverage, and dose distributions.
• Automated analysis software provided color-coded results for plan approval, with group consensus determining outcomes.

Main Results:

• Approximately 8% of radiation oncology treatment plans required re-planning.
• Around 23% of plans necessitated minor modifications.
• The average review time per plan was 8 minutes.

Conclusions:

• Pre-treatment error detection is the sole method to achieve "zero harm" in radiation oncology.
• The GCPR model effectively prevents a wide range of errors in target definition, dose prescription, and treatment planning.
• This multidisciplinary approach ensures that treatment plans are safe and accurate before patient delivery.