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Patient Safety Improvement Related to Changes in Ongoing Radiation Treatment Plan Identified with Near-Miss Incidents Reporting

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J Zeng

J Zeng*, M Nyflot, P Sponseller, A Kusano, A Novak, L Jordan, J Carlson, R Ermoian, G Kane, E Ford, University of Washington, Seattle, WA

SU-E-T-230 Sunday 3:00PM - 6:00PM Room: Exhibit Hall

Purpose: A significant portion of patients undergoing radiation experience a change in the treatment plan during the treatment course for a variety of reasons, including adaptive planning due to tumor response and change in fractionation due to patient clinical status. This study tests whether mid-course changes to treatment plans increase risk of errors through the use of a large institutional near-miss incident reporting system.

Methods: We analyzed incidents from a departmental near-miss incident reporting system launched in 2/2012. All incidents were prospectively reviewed weekly by a multi-disciplinary team including physicians, therapists, dosimetrists, physicists, nurses, and administrative staff. Incidents were assigned a near-miss severity score ranging from 0 to 4 (no impact/mild/moderate/severe/critical), reflecting the potential harm of the incident if it had reached the patient. Monthly root-case-analysis is performed on incidents with the highest severity. Incidents related to change-in-plan were flagged, and severity score for these were compared to other incidents via t-test.

Results: From 2/2012 through 12/2012, 662 incidents were submitted through the departmental near-miss incident reporting system. On multi-disciplinary review, 59(9%) incidents were directly attributable to a change-in-plan. Average severity score for the 59 change-in-plan incidents was 1.9, significantly higher than score of 1.5 for other incidents not related to change-in-plan (p=0.02). Three(5%) near-miss incidents were assigned the highest severity score of 4, with issues including: wrong isocenter, wrong fields assigned to new plan, and wrong information in new treatment plan due to existing plan.

Conclusion: Changes in treatment plan are sometimes required to provide highest quality of care for patients receiving radiation. Although near-miss incidents related to change-in-plan are relatively uncommon, when they do occur they are more severe than other types of incidents that are observed in the course of clinical operations. Development is underway for new safety process specifically tailored to this identified high-risk patient group.

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