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The Impact of Pre-Treatment Planning Peer-Review Rounds On Patient Safety

A Kapur

A Kapur*, L Potters , H Chou , B Cox , Long Island Jewish Medical Center, New Hyde Park, NY


SU-I-GPD-P-12 (Sunday, July 30, 2017) 3:00 PM - 6:00 PM Room: Exhibit Hall

Purpose: Multidisciplinary pre-treatment planning peer review has the potential to enable early identification of errors, assure standardized care and provide continuous learning. In this work we validate the impact of such peer reviews on patient safety using an incident learning system (ILS).

Methods: The suitability of contours and treatment directives for all patients was reviewed daily by physicians, residents, physicists and therapists in our multi-site department starting in 2012 via video-conferences. Each case was assigned a grade of A, B or C respectively for no, minor and major changes recommended per peer-review using departmental instituted pathways. Subsequent reviews with grade improvement requirements were enforced for cases with C grades prior to commencing treatment planning. In our departmental ILS incidents encompassing aspects of care including safety were independently registered by all staff. Peer-review grades were retrospectively compared with safety incidents registered from 2013 through 2016.

Results: Of the 7959 peer-reviewed cases, 74.2%, 19.3% and 6.5% were assigned grades of A,B and C respectively. 7.7% of these cases were associated with preventive (N=473, such as pre-treatment good catches) or reactive (N=136,such as incidents that reached the patient) safety incidents. 8.1, 9.4 and 2.7% of the A,B and C cases respectively were associated with these incidents (1.9, 2.0 and 0.3% for reactive incidents respectively). Reactive incidents that included dose or volume deviations corresponded to 0.3, 0.3 and 0.1% of the A,B and C cases respectively.

Conclusion: There was a tendency for the cases with major changes recommended to be coupled with fewer safety incidents potentially due to the enhanced scrutiny afforded upstream, although trends changed over time. Yet the need for opportunities to seek improvements in mitigating downstream errors for 93.5% of the cases became apparent. Peer review has raised awareness of the need for such opportunities to be pursued in future studies.

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