Human Error Bowtie Analysis to Enhance Patient Safety in Radiation Oncology.

PURPOSE: Ensuring safety within RT is of paramount importance. To further support and augment patient safety efforts, the purpose of this research was to test and refine a robust methodology for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs. METHODS: The method proposed for performing Bowtie Analysis (BTA) was based on training and recommendations from practitioners in the field of Human Factors and Ergonomics practice. Multidisciplinary meetings to iteratively develop BTA focused on incorrect site setup instructions was conducted. RESULTS: From November 2015 to February 2017, we had 12 reported incidents related to site setup notes that could have led to site setup errors. Based on this data, we conducted five BTA analyses related to incorrect site setup instructions. None of the individual controls within our QA program designed to check for potential errors with site setup instructions met the level of robustness to be classified as key safeguards or barriers. CONCLUSIONS: The relatively low number of incidents causing patient harm has led us to typically assume that we have sufficient and effective controls in place to prevent serious human errors from leading to severe patient consequences. Based on our BTA, we question how well we truly understand the details of our individual controls. To meet the level of safety achieved by high reliability organizations (HROs), we need to better ensure that our controls are as reliable and robust as we assume.

Predicting Radiation Therapy Process Reliability Using Voluntary Incident Learning System Data.

PURPOSE: This study aimed to present an innovative approach to quantify, visualize, and predict radiation therapy (RT) process reliability using data captured from a voluntary incident learning system, with an overall aim to improve patient safety outcomes. METHODS AND MATERIALS: We analyzed 111 reported deviations that were tripped and caught within 159 mapped RT process steps included within 7 major stages of RT delivery, 94 of which were any type of quality assurance (QA) controls. This allowed for us to compute the trip rate and fail-to-catch-rate (FCR) per each QA control with the available data. Next, we used a logistic regression model to identify significant variables predictive of FCRs, predicted FCRs for each QA control without available data, and thus, attempted to quantify RT process reliability expressed as percentage of patients with uncaught deviations after treatment planning, before their first treatment, and during treatment delivery. RESULTS: Using the predicted FCRs, we computed the upper 95% likelihood that a deviation remains uncaught in a patient's course of treatment at the following RT process stages: immediately after treatment planning at 10.26%; before the first treatment at 0.0052%; and throughout treatment delivery at 0.0276%. CONCLUSIONS: The results suggest that RT process reliability can be predicted and visualized using data from incident learning systems. If implemented and used as a safety metric, this could help RT clinics to proactively maintain their preoccupation with patient safety. RT process reliability may also help guide future work on standardization and continuous improvement of the design of RT QA programs.

Integrating Lean Exploration Loops Into Healthcare Facility Design.

PURPOSE: To explore how Lean can add value during the schematic phase of design through providing additional resources and support to project leadership and the architectural design team. BACKGROUND: This case study-based research took place at one large academic hospital during design efforts of surgical tower to house 19 operating rooms (ORs) and support spaces including pre- and post-op, central processing and distribution, and materials management. Surgical services project leadership asked for Lean practitioners' support during the design process. METHODS: Lean Exploration Loops (LELs) were conducted to generate evidence to support stakeholders, as they made important decisions about the new building design. The analyses conducted during LELs during the schematic phase were primarily conducted using express workouts (EWOs) and were focused on the flow of patients, staff, and family throughout the pavilion. RESULTS: LELs resulted in recommendations for key design features (e.g., number of pre- and post-op bays per OR floor, location of doors, scrub sinks, stretcher alcoves, equipment storage, and sterile core areas). Two-sided pre- and post-op bays with an inner clinical workspace and an outer patient transport corridor were recommended. Communicating elevator and a centrally located stairwell for staff to alleviate stress on the main bank of elevators at peak usage times were also suggested. CONCLUSIONS: We found Lean tools and methods to be of most value during schematic phase when focused on detailed process and layout analysis, while acknowledging the usefulness of focused EWOs to generate the evidence needed for the decision-making.

Primary cilia are sensors of electrical field stimulation to induce osteogenesis of human adipose-derived stem cells.

In this study, we report for the first time that the primary cilium acts as a crucial sensor for electrical field stimulation (EFS)-enhanced osteogenic response in osteoprogenitor cells. In addition, primary cilia seem to functionally modulate effects of EFS-induced cellular calcium oscillations. Primary cilia are organelles that have recently been implicated to play a crucial sensor role for many mechanical and chemical stimuli on stem cells. Here, we investigate the role of primary cilia in EFS-enhanced osteogenic response of human adipose-derived stem cells (hASCs) by knocking down 2 primary cilia structural proteins, polycystin-1 and intraflagellar protein-88. Our results indicate that structurally integrated primary cilia are required for detection of electrical field signals in hASCs. Furthermore, by measuring changes of cytoplasmic calcium concentration in hASCs during EFS, our findings also suggest that primary cilia may potentially function as a crucial calcium-signaling nexus in hASCs during EFS.-Cai, S., Bodle, J. C., Mathieu, P. S., Amos, A., Hamouda, M., Bernacki, S., McCarty, G., Loboa, E. G. Primary cilia are sensors of electrical field stimulation to induce osteogenesis of human adipose-derived stem cells.

Incidence of invasive breast cancer and ductal carcinoma in situ in a screening program by age: should older women continue screening?

OBJECTIVE: The evidence for the effectiveness of screening is strongest for women ages 50 to 69 years; however, there is variation in the target age group for screening programs between different countries. In particular, there is uncertainty over whether women should continue screening once they reach age 70. We therefore investigated incidence rates for invasive and in situ breast cancer by age as well as prognostic features of tumors within a screening program. METHODS: We studied 474,808 women who attended BreastScreen Victoria from January 1, 1993 to December 31, 2000. Of these women, 5,301 were diagnosed with invasive cancer and 1,127 were diagnosed with ductal carcinoma in situ. We used generalized additive models to model age-incidence rates for invasive cancers and ductal carcinoma in situ separately by users and nonusers of hormone replacement therapy at most recent screen. Nonparametric trends for ordered groups and regression methods were used to investigate trends in size, grade, and nodal involvement for invasive tumors by type of attendance and time since previous negative screen for age group. RESULTS: The incidence of ductal carcinoma in situ among women with a previous negative screen clearly declined after age 70 irrespective of hormone replacement therapy use. At subsequent screen, the age-incidence curve for invasive breast cancer flattened at ages 60 to 75 years and then increased only for women taking hormone replacement therapy. Tumor size at diagnosis declined with age at both first round (P = 0.15) and subsequent round (P = 0.08). The proportion of poorly differentiated tumors also decreased with age, with the smallest proportion of grade III tumors diagnosed in women ages > or = 75 years (P = 0.09 for first screen and P = 0.05 for subsequent screen). The presence of positive nodes at diagnosis declined with age (P < 0.001) for both first and subsequent screening rounds. CONCLUSION: Older age is associated with more favorable prognostic tumor features and a lower incidence of ductal carcinoma in situ among subsequent attenders of screening. When making decisions regarding continuing screening, older women and their physicians should also consider the presence of other comorbid conditions that may mitigate any impact of screening on mortality.

Duration of hormone replacement therapy, breast tumour size and grade in a screening programme.

UNLABELLED: One of the primary adverse effects of long-term use of hormone replacement therapy (HRT) is a modest increase in the risk of breast cancer. Breast tumours that develop in women using HRT have been shown to have prognostically favourable histological features but it is unclear if this is the case for both short- and long-term use. METHODS: We evaluated the association between HRT use with tumour size and histologic grade in a cohort of women aged over 55 years (n = 2200) diagnosed with invasive breast cancer at subsequent screen in BreastScreen Victoria (BSV), Australia between 1993 and 2000. BSV biennially screens women aged over 40 years with the target age group 50-69 years. Multiple linear regression was used to examine predictors of log-transformed tumour size and multinomial logistic regression was used to evaluate associations of HRT with tumour grade. RESULTS: Short-term users of HRT (< or = 5 years), were approximately 50% less likely to develop poorly-differentiated breast tumours OR 0.48 95% CI (0.28-0.82) or node-positive tumours OR 0.57 95% CI (0.35-0.94) than non-users. Long-term users of HRT (> 5 years) were also less likely to develop poorly-differentiated tumours OR 0.36 95% CI (0.24-0.56) but were not more likely to be node-positive than women not on HRT. Duration of HRT use was not significantly associated with tumour size. CONCLUSION: HRT use, regardless of duration, was associated with breast tumours that were better differentiated and not significantly larger than women not on HRT, although only short-term use was associated with fewer node-positive tumours.