Encrypted login | home

Program Information

Novel Applications of Tracking Principles to Improve Incorrect Patient Setup Instruction Errors

D DiCostanzo

D DiCostanzo*, J Woollard , K Hintenlang , Ohio State University Medical Center, Columbus, OH


SU-I-GPD-J-40 (Sunday, July 30, 2017) 3:00 PM - 6:00 PM Room: Exhibit Hall

Purpose: To demonstrate the effectiveness of good catch tracking processes in decreasing patient setup errors.

Methods: A good catch tracking process was implemented for high volume, high impact procedures. One specific event tracking category, Incorrect Setup Instructions, was identified by the Departmental Safety Committee as having a high number of events. Investigations into the root cause of the incorrect setup instructions showed that a greater number of events than previously reported were taking place and required corrective action. A critical review of CT simulation documentation demonstrated that patient setup instructions that were required to be manually transferred into the record and verify system were producing transcription errors. A novel scripting program was developed to extract discrete data elements from the CT simulation documentation and auto-populate the record and verify system setup fields.

Results: Implementation of an automated scripting program provided an order of magnitude decrease in the frequency of incorrect setup instructions being transferred to the record and verify system. An initial training period on the program was necessary to fully realize the benefits of the program.

Conclusion: Automated scripting of previously manually entered setup instructions provided a significant decrease in the frequency of incorrect setup instructions being entered. The good catch tracking processes implemented through a robust safety committee review provided an effective means of identifying important potential issues and for tracking corrective action performance after its implementation.

Contact Email: