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Lessons From the Radiation Oncology Incident Learning System (RO-ILS): Early Process Errors

G Ezzell

G Ezzell1*, B Chera2 , A Dicker3 , E Ford4 , B Fraass5 , D Hoopes6 , T Kwiatkowski7 , K Lash8 , G Patton9 , L Potters10 , L Santanam11 , S Weintraub12 , (1) Mayo Clinic Arizona, Phoenix, AZ, (2) University of North Carolina, Chapel Hill, NC, (3) Thomas Jefferson Univ Hospital, Philadelphia, PA, (4) University of Washington, Seattle, WA, (5) Cedars-Sinai Medical Center, Los Angeles, CA, (6) University of California San Diego, San Diego, CA, (7) Rochester General Hospital, Rochester, NY, (8) University of Michigan Medical Center, Ann Arbor, MI, (9) Compass Oncology, Portland, OR, (10) Northwell Health, Lake Success, New York, (11) Washington University School of Medicine, St.Louis, MO, (12) Southcoast Health, Fair Haven, MA


TU-FG-702-7 (Tuesday, August 1, 2017) 1:45 PM - 3:45 PM Room: 702

Purpose: Identify error pathways that occurred early in the treatment process, safety barriers that failed or succeeded, and potential improvement strategies.

Methods: Through September, 2016, 2344 events had been entered into the Radiation Oncology Incident Learning System (RO-ILS). The designated review committee analyzed the 396 most significant events to identify common error pathways and record where the error was caught and by whom.

Results: In 100 events, the plan differed from the physician’s intent; 43 reached the patient. 31 events were flagged by physicists. Common error pathways included:(A) Target definition errors: 25 events; 6 events: laterality errors – target drawn on wrong side; 9 events: target choice errors – wrong target chosen in liver, brain, lung, spine, or skin; 8 events: planning errors involving targets – PTV margins not applied or targets missed in planning; 2 events: other errors in defining targets. Examples: trigeminal neuralgia SRS to wrong side prevented by therapist timeout; benign liver lesion treated to 50 Gy instead of the malignant lesion.(B) Dose and fractionation scheme in the plan not matching the physician’s intent: 23 events; 2 events: the planner misunderstood the intent and wrote the prescription, which was approved; 2 events: the physician erred in writing the prescription, which was planned and later corrected; 3 events: reversal of the dose/fraction and number of fractions, leading to plans with 180 or 200 fractions; 16 events: unexplained reason for the mismatch between the prescription and the plan. Example: Verbal “12 in 2” interpreted as 2 Gy in 6 fractions instead of 6 Gy in 2 fractions.(C) Relevant previous treatment not accounted for: 9 events. Example: multiple handoffs between physicians.

Conclusion: Target definition, dose/fractionation and prior radiotherapy are error pathways that escape current quality assurance processes. Pre-planning target review and automated plan checking are potential improvement strategies.

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