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5 Ways to Prevent Radiation Therapy Errors

 |  By cclark@healthleadersmedia.com  
   August 08, 2011

With increased attention on patients harmed and nearly harmed, by radiation therapy errors, researchers at two hospitals say they have isolated five checks, which, if used consistently, would have prevented 97% of 4,000 errors and near misses identified in a three-year period.

"The key to this whole thing,  to learn and improve the quality of our treatments and patient safety,  is to look carefully at what happens in our (radiation clinics) and paying attention to these near misses," said Eric Ford, assistant professor of radiation oncology and Molecular Radiation Sciences at Johns Hopkins University.

"We call it a free lesson; it doesn't hurt anyone, although it comes close, but we have learned from that."

Ford and researchers at Washington University in St. Louis, gathered voluntarily contributed information on about 4,000 errors and near misses that occurred during cancer care at the two hospitals and scrutinized 290, which would have resulted in serious harm, such as radiation to the wrong body part or wrong dosage.

They then looked at 13 commonly employed quality assurance measures to see which ones would have had the great likelihood of catching the error or near miss before it occurred. 

They narrowed it down to these five:
  1. Use of  an Electronic Portal Imaging Device or EPID would gave caught about 83%
  2. Treatment plan check by a physicist would have caught 63%.
  3. Use of port films would have caught 53% of errors.
  4. Check by the radiation therapist would have caught 35%.
  5.  Proper use of standard radiation therapy checklists, such as assuring that
  • The patient is the correct patient
  • The patient is not pregnant
  • Treatment is directed at correct body part,
  • Both physicians and radiation physicists have reviewed patient charts to calculate the correct radiation dose also had a significant error capture success rate.

Their report was presented as an abstract last week at the joint American Association of Physicists in Medicine (AAPM) and Canadian Organization of Medical Physicists annual meeting in Vancouver.

One finding from the research was that EPID hardware, which is now more commonly used in Europe but rarely in the U.S., is especially effective at avoiding near misses. The device is built into radiation machinery and provides a realtime image of precisely where the radiation is hitting the patient. Fewer than 1% of radiation clinics use the device because software and training are not available.

A second finding is that a quality assurance measure commonly known as "pretreatment intensity modulated radiation therapy or IMR, in which clinicians do a test run at its programmed strength with no patient present, ranked zero in effectiveness at preventing near misses and errors.

Ford and his research colleagues are calling for a "national radiotherapy incident reporting system" so that treatment errors and near misses can be sent to a central group for evaluation and dissemination to clinics.

National attention on the incidence ofharm from radiation errors has intensified since January of 2010 when a series in The New York Times revealed systemic problems in processes, error recognition and detection, and lethal consequences in many of the one million patients treated annually with radiation for cancer. The series explained how the errors were not only underreported, but under recognized, in part because the patients were already sick.

Ford said the series described some "incredibly bad radiation errors that had some horrible consequences for patients."

And while for "those of us who work in this field, this issue has never been under-appreciated," he said it's now receiving "extra attention" from health providers, including hospital leaders, and others "who didn't normally think about it."

Asked what hospital executives, physicians and radiation oncology specialists should learn from this report, Ford said:

"The most fruitful thing would be to look at the operation from a system point of view and organize yourself around that. We need to start looking at this not as an individual failing of what someone does, or a piece of the puzzle breaking, but that it's more of a system problem.

"How do you put these checks together in a coherent way to make your system work in a way that would be less inclined to let an error slip through."

Some of the strategies, Ford says, are simple "low-hanging fruit," while others may take some time and investment. But no matter what, he says, " we have to get to as close as possible to a zero rate of error."

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