A Qualitative Analysis of Human Error During the DIBH Procedure

Area of Science:

• Medical Physics
• Radiation Oncology
• Human Factors Engineering

Background:

• Quality assurance study analyzing human errors in deep-inspiration breath hold (DIBH) radiation therapy delivery.
• Focuses on a tertiary cancer center to identify and mitigate errors in a specialized treatment technique.

Purpose of the Study:

• To analyze human errors during DIBH radiation therapy delivery.
• To recommend system changes and solutions based on human factors principles to decrease error frequency.
• To improve patient safety in radiation oncology.

Main Methods:

• Analysis of 82 incident reports from January 2012 to July 2017.
• Identification of performance-influencing factors through incident reports and focus groups with radiation therapists.
• Literature search and expert interviews to identify potential solutions.
• Ranking of solutions by effectiveness and classification using a priority matrix.

Main Results:

• 89% of errors were slip/lapse types; 11% were mistake types.
• Causative factors included treatment-related problem-solving and distractions/interruptions.
• Suggested solutions: forcing functions (e.g., real-time position management), reminders (e.g., console sign-off), and updated checklists.

Conclusions:

• Four key recommendations: 1) forcing function, 2) procedure update/reinforcement, 3) workload management, 4) checklist update.
• Recommends implementing procedures, workload management, and checklist updates together as an interim solution.
• Proposes a human factors-based method for analyzing specialized procedures to reduce errors in cancer patient treatment.