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Program Information

Systematic Reduction of Table Position Overrides and Radiation Incidents During External Beam Radiation Therapy

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N Yu

N Yu*, E Murray , T Meier , P Barrett , J Suh , S Chao , P Xia , The Cleveland Clinic Foundation, Cleveland, OH


TH-AB-FS1-14 (Thursday, August 3, 2017) 7:30 AM - 9:30 AM Room: Four Seasons 1

Purpose: Treatment table indexing is an effective means to reduce radiation incidents and is widely used in radiation therapy. Occasional overrides of table positions are still needed to allow a smooth workflow. In the last five years, our institution has implemented measures to reduce such overrides. These measures included standardization of documentation, consolidation of table position tolerance tables, and continuous automatic monitoring of overrides and daily and monthly review of overrides. We report the reduction of overrides and incidents through this effort.

Methods: The department R&V system (MOSAIQ) was queried for the number of fractions treated with and without table position overrides in the longitudinal, lateral and vertical positions for all treatments from 1/1/2012 to 11/30/2016. Overrides for the first fraction of treatment of a site, or for the first fraction after a machine change were excluded. The internal department continuous improvement database was queried for radiation incidents and the association with overrides. Radiation incidents are any radiation to a region not prescribed by physician, although clinically all the incidents included in this study were minor. Odds ratio for radiation incidence for treatment with and without overrides were computed. The yearly override and incidence rate were also obtained to show trend of reduction over time.

Results: From 2012 to 2016, 115667 fractions were treated without overrides, one had incidents, 11855 fractions were treated with overrides, 14 had incidents. The odds ratio of incidence for the two types of treatment was 195.6 (p<0.001, Fisher exact test). From 2012 to 2016, the yearly overrides was reduced from 2959 for 2012 to 675 for 2016 (annualized), the yearly incidents were reduced from 7 to 1.

Conclusion: Standardization of documentation and tolerance tables and automatic monitoring and reviewing effectively reduced the number of overrides with corresponding reduction of radiation incidents.

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