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Targeting Safety Improvements Through Analysis of Near-Miss Error Detection Points in An Incident Learning Database

M Nyflot

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


SU-E-T-310 Sunday 3:00PM - 6:00PM Room: Exhibit Hall

Radiation treatment planning involves a complex workflow that can make safety improvement efforts challenging. This study utilizes an incident reporting system to identify detection points of near-miss errors, in order to guide our departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or their patterns.

1377 incidents were analyzed from a departmental near-miss error reporting system from 3/2012-10/2013. All incidents were prospectively reviewed weekly by a multi-disciplinary team, and assigned a near-miss severity score ranging from 0-4 reflecting potential harm (no harm to critical). A 98-step consensus workflow was used to determine origination and detection points of near-miss errors, categorized into 7 major steps (patient assessment/orders, simulation, contouring/treatment planning, pre-treatment plan checks, therapist/on-treatment review, post-treatment checks, and equipment issues). Categories were compared using ANOVA.

In the 7-step workflow, 23% of near-miss errors were detected within the same step in the workflow, while an additional 37% were detected by the next step in the workflow, and 23% were detected two steps downstream. Errors detected further from origination were more severe (p<.001; Figure 1). The most common source of near-miss errors was treatment planning/contouring, with 476 near misses (35%). Of those 476, only 72(15%) were found before leaving treatment planning, 213(45%) were found at physics plan checks, and 191(40%) were caught at the therapist pre-treatment chart review or on portal imaging. Errors that passed through physics plan checks and were detected by therapists were more severe than other errors originating in contouring/treatment planning (1.81 vs 1.33, p<0.001).

Errors caught by radiation treatment therapists tend to be more severe than errors caught earlier in the workflow, highlighting the importance of safety checks in dosimetry and physics. We are utilizing our findings to improve manual and automated checklists for dosimetry and physics.

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