1. HOW RO-ILS HELP DOSIMETRISTS TO IMPROVE PATIENT SAFETY
Kalpana Vaidya, MSc, CMD; Raymond Chan, MSc, CMD; Yijian Cao, Ph.D, DABMP;
Katrina Aronoff R.T(T), BS; Louis Potters, MD, FACR, FASTRO
OBJECTIVES
The objective of this study is to improve the radiation treatment planning workflow for Medical Dosimetrists, who adhere to site-specific treatment directives written in the radiation prescription by the physician. Any discrepancies between the treatment directive and the prescription can lead to major errors when delivering radiation to the patient. Our multi-site radiation oncology department uses a Radiation Oncology-Incident Learning System (RO-ILS) which is a web based incident reporting system used to track and document these discrepancies in the pre-treatment, during, and post-treatment planning process. The data collected will provide corrective actions, workflow accountability for dosimetrists and physicians, and assist in avoiding errors which will enhance patient safety.
MATERIALS and METHODS
RO-ILS is a web based incident reporting system that provides a global mechanism for collaborating learning with radiation oncology (Figure 1). Our department treatment directive is a set of guidelines for all aspects of radiation treatment delivery, which include prescription, simulation instructions, planning dose constraints, and treatment filming rules (Figure 2).
The submitted incidents to RO-ILS can be any discrepancies between directive and prescription, and/or missing information. These incidents can be in three stages (Pre, During, and Post) of the treatment planning process.
Pre-planning
Before a treatment plan is generated, each patient is presented at our daily chart rounds. The clinicians peer review contours/fields, dose prescription, and treatment directives with input from dosimetrists, physicists and therapists.
If there is any variance between the initial treatment directive and prescription, the physician is notified and an entry is entered into RO-ILS. This will result in putting the treatment plan on hold until the directive and prescription are in agreement and may cause a delay in the planning workflow. A directive and prescription mismatch may have severe consequences on patient safety. For example, using an incorrect directive’s dose constraints may potentially lead to an overdose of normal tissue (Figure 3).
Figure 2. Treatment Directive
RESULTS
CONCLUSION
REFERENCES
Figure 3. Prescription and Treatment Directive mismatch
During Planning
While reviewing the plan, physicians may decide to add a new dose constraint or modify an existing one. This will generally result in a re-plan, especially a plan requiring re-optimization. This will be considered as a deviation from the original directive previously reviewed in chart rounds. Another frequent occurrence was issue with the use of bolus. The request for bolus often was made after plan review when bolus was not ordered in the original treatment directive, which is the first place therapists look for setup instructions.
Post-planning
Machine changes can occur due to scheduling conflicts (patient unable to fill their assigned machine’s time slot) or the patient’s inpatient/outpatient status. Since a new plan, sometimes with different energies due to machine capability, is typically required as a result of a machine change, patients may have a delay in start of treatment or a gap in between treatment
Dosimetrists are notified to generate a plan once the treatment directive and radiation prescription are in agreement and signed off by the attending physician. This step-by-step process is in place ensuring patient safety. If the planner or the physician catches a discrepancy, the event is reported into RO-ILS. The data is then reported back to the Directives Committee, which enables them to use the data collected to analyze what needs to be done to improve patient safety and work flow (Figure 4).
The entries into RO-ILS provides a database of departmental incidents and near-miss/good catches and is available for our staff to learn from and gives opportunity for improvement on future processes to enhance patient safety. As much as any other quality improvement tool, this requires support of staff and management in order to be sustaining and of optimal use. Its success is contingent on the whole team, availability of time and resources and appropriate training
Thomadsen, Bruce R., Peter Dunscombe, Eric Ford, Saiful Huq, Todd Pawlicki, Steven Sutlief, ed. Quality and Safety in Radiotherapy learning the New Approaches in Task Group 100 and Beyond. American Association of Physicist in Medicine, Medical Physics Monograph No
Potters, L., Raince, J., Chou, H., Kapur, A., Bulanowski, D., Stanzione, R. and Lee, L. (2013). Development, Implementation, and Compliance of Treatment Pathways in Radiation Medicine. Front Oncol, 3:105. doi: /fonc eCollection 2013.
Figure 1. Radiation Oncology-Incident Learning system website
Figure 4. Incident Reports submitted into RO-ILS