A bi-institutional multi-disciplinary failure mode and effects analysis (FMEA) for a Co-60 based total body irradiation technique.

BACKGROUND: We aim to assess the risks associated with total body irradiation (TBI) delivered using a commercial dedicated Co-60 irradiator, and to evaluate inter-institutional and inter-professional variations in the estimation of these risks. METHODS: A failure mode and effects analysis (FMEA) was generated using guidance from the AAPM TG-100 report for quantitative estimation of prospective risk metrics. Thirteen radiation oncology professionals from two institutions rated possible failure modes (FMs) for occurrence (O), severity (S), and detectability (D) indices to generate a risk priority number (RPN). The FMs were ranked by descending RPN value. Absolute gross differences (AGD) in resulting RPN values and Jaccard Index (JI; for the top 20 FMs) were calculated. The results were compared between professions and institutions. RESULTS: A total of 87 potential FMs (57, 15, 10, 3, and 2 for treatment, quality assurance, planning, simulation, and logistics respectively) were identified and ranked, with individual RPN ranging between 1-420 and mean RPN values ranging between 6 and 74. The two institutions shared 6 of their respective top 20 FMs. For various institutional and professional comparison pairs, the number of common FMs in the top 20 FMs ranged from 6 to 13, with JI values of 18-48%. For the top 20 FMs, the trend in inter-professional variability was institution-specific. The mean AGD values ranged between 12.5 and 74.5 for various comparison pairs. AGD values differed the most for medical physicists (MPs) in comparison to other specialties i.e. radiation oncologists (ROs) and radiation therapists (RTs) [MPs-vs-ROs: 36.3 (standard deviation SD = 34.1); MPs-vs-RTs: 41.2 (SD = 37.9); ROs-vs-RTs: 12.5 (SD = 10.8)]. Trends in inter-professional AGD values were similar for both institutions. CONCLUSION: This inter-institutional comparison provides prospective risk analysis for a new treatment delivery unit and illustrates the institution-specific nature of FM prioritization, primarily due to operational differences. Despite being subjective in nature, the FMEA is a valuable tool to ensure the identification of the most significant risks, particularly when implementing a novel treatment modality. The creation of a bi-institutional, multidisciplinary FMEA for this unique TBI technique has not only helped identify potential risks but also served as an opportunity to evaluate clinical and safety practices from the perspective of both multiple professional roles and different institutions.

Ten-year trends in safe radiation therapy delivery and results of a radiation therapy quality assurance intervention.

PURPOSE: This study reviews our institutional error data and assesses the effectiveness of a policy implemented January 1, 2011, as a "no rushed treatment" initiative to avoid universal, large-scale replanning for all patients in the event that a treatment unit is down for ≤1 day. METHODS AND MATERIALS: Radiation error data between January 1, 2004, and December 31, 2014, were reviewed to determine absolute delivery error rates. Variables were compared (using a χ(2) or Fisher exact test) before and after the policy change, including planning versus delivery error status and differences in error type. We also evaluated time of day in relation to therapist shift change, deviation from scheduled time, and weekend treatment as predictors of error using a test of proportions or χ(2) test. RESULTS: Treatment delivery error rate over the entire period was 0.18% per fraction; the rate before intervention was 0.24% and after was 0.08%, P < .001. For the 5 years for which detailed records were available (2010-2014), 109 delivery errors were reported. Delivery error rate was 0.09%; before intervention 0.15% versus after, 0.08% (P = .005) and 94% were level 1 errors. Fifty-six percent were primary planning errors and 44% were primary delivery errors. Before intervention, large-scale replanning occurred 18 times/year versus 4.5/year after, with 21% versus 12% of errors directly attributable to large-scale replanning. Fourteen error reports specifically implicated a rushed environment as causal. There was no significant difference in error rate based on time of day (P = .631). Error rates were higher for weekend simulation and treatments, 1.3% versus 0.09% per fraction (P < .001). CONCLUSIONS: Delivery error rates at our institution were similar compared with published series from other academic institutions. A significant improvement in delivery error rate was appreciated after implementation of a "no rushed treatment" initiative. A significantly higher error rate for weekend treatments was noted, warranting consideration of additional quality assurance measures.

Compliance of reviewing portal images on radiographic film vs an electronic medical record.

PURPOSE: Timely approval of weekly portal images is essential for quality patient care. Most departments stipulate that portal images should be reviewed within 1 to 2 business days after imaging. The purpose of this study was to compare compliance of reviewing portal images per departmental policy before and after implementing an electronic medical record (EMR). METHODS: The use of an EMR to review portal images was initiated at the investigators' institution in March 2010. Before this, portal images were reviewed on either radiographic film or printouts from machines equipped with electronic portal imaging. The EMR could be accessed remotely by any computer with direct access to the institution's network. Patients selected were those treated by attending physicians present before and after the switch to the EMR. Patients were randomly selected for review of their portal images from 2009 for radiographic film and March to June 2010 for portal images in the EMR. Violations of department policy included unsigned portal images, undated portal images, no date documented when signed by the attending physician, and portal images signed after >1 business day. Violations for each portal image counted only once, even if the portal image had multiple types of violations. RESULTS: A total of 411 portal images were evaluated. Two hundred four radiographic films taken on 22 different patients were hand signed by 6 different attending physicians. Two hundred seven portal images taken on 16 different patients were reviewed via the EMR by the same 6 attending physicians. Twenty-five percent (51 of 204) of portal images reviewed by hand on radiographic films incurred violations, while 1% (2 of 207) of portal images reviewed via the EMR incurred violations. When portal images were reviewed by hand, 16 (8%) did not have the film date documented when taken by the therapists, 2 (1%) did not have documentation of date signed, 16 (8%) were never signed, and 17 (8%) were signed after 1 business day. All violations incurred with the EMR were for films signed after >1 business day. Chi-square analysis showed a significant improvement in compliance with reviewing portal films with the EMR (P < .001). CONCLUSIONS: The use of an EMR for reviewing portal images dramatically improved compliance with timeliness and record keeping. Timeliness of reviewing portal images improves patient care and safety.