Quality Improvement Process with Incident Learning Program Helped Reducing Transcriptional Errors on Telecobalt Due...

Area of Science:

• Medical Physics
• Radiotherapy Quality Assurance
• Health Informatics

Background:

• Radiotherapy electronic charts are prone to transcriptional errors, particularly with telecobalt therapy.
• A high baseline transcription error rate of 44.14% was observed, posing risks to patient safety.

Purpose of the Study:

• To implement and evaluate a quality improvement (QI) initiative to reduce transcription errors in radiotherapy electronic charts.
• To decrease the transcription error rate from 40% to below 5% within 12 months using an incident learning program (ILP).

Main Methods:

• A multidisciplinary team conducted a root cause analysis (fishbone diagram, Pareto chart) to identify key error drivers.
• The Plan-Do-Study-Act (PDSA) cycle strategy was employed, focusing on staff education and machine parameter synchronization.
• The primary outcome was the monthly percentage of charts with transcription errors; errors were corrected before patient treatment.

Main Results:

• Following an educational intervention (PDSA cycle 1), the error rate decreased to 5.4% (P=0.03).
• Further synchronization of machine parameters (PDSA cycle 2) sustained the error rate between 3-5% over one year (P>0.05), with no new errors introduced.
• Key drivers identified were workforce education and mechanical synchronization of machine parameters.

Conclusions:

• Transcription errors in radiotherapy are significantly influenced by the synchronization of diverse machine technologies.
• A structured quality improvement process within an incident learning program can effectively identify and mitigate these transcription errors.
• Implementing QI initiatives is crucial for enhancing patient safety in radiotherapy departments.