An automated electronic system for managing radiation treatment plan peer review reduces missed reviews at a large, high-volume academic center.

BACKGROUND: Assuring quality in cancer care through peer review has become increasingly important in radiation oncology. In 2012, our department implemented an automated electronic system for managing radiation treatment plan peer review. The purpose of this study was to compare the overall impact of this electronic system to our previous manual, paper-based system. METHODS AND MATERIALS: In an effort to improve management, an automated electronic system for case finding and documentation of review was developed and implemented. The rates of missed initial reviews, late reviews, and missed re-reviews were compared for the pre- versus postelectronic system cohorts using Pearson χ2 test and relative risk. Major and minor changes or recommendations were documented and shared with the assigned clinical provider. RESULTS: The overall rate of missed reviews was 7.6% (38/500) before system implementation versus 0.4% (28/6985) under the electronic system (P < .001). In terms of relative risk, courses were 19.0 times (95% confidence interval, 11.8-30.7) more likely to be missed for initial review before the automated system. Missed re-reviews occurred in 23.1% (3/13) of courses in the preelectronic system cohort and 6.6% (10/152) of courses in the postelectronic system cohort (P = .034). Late reviews were more frequent during high travel or major holiday periods. Major changes were recommended in 2.2% and 2.8% in the pre- versus postelectronic systems, respectively. Minor changes were recommended in 5.3% of all postelectronic cases. CONCLUSIONS: The implementation of an automated electronic system for managing peer review in a large, complex department was effective in significantly reducing the number of missed reviews and missed re-reviews when compared to our previous manual system.

Journey Toward High Reliability: A Comprehensive Safety Program to Improve Quality of Care and Safety Culture in a Large, Multisite Radiation Oncology Department.

BACKGROUND: High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology. METHODS: In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade. RESULTS: Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Postintervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P < .0075) and 21,678 to 113,104 fractions (P < .0028) preintervention and postintervention, respectively. Agency for Healthcare Research and Quality results demonstrate a high patient SC grade over time. CONCLUSION: Our journey toward becoming an HRO has led to the development of a robust SC through a comprehensive safety framework. Our multifaceted initiatives, focusing on culture and system changes, can be successfully implemented in a large academic radiation oncology department to yield measurable improvements in SC and outcomes.

The implementation and assessment of a quality and safety culture education program in a large radiation oncology department.

UNLABELLED: In 2010, the American Society for Radiation Oncology launched a national campaign to improve patient safety in radiation therapy. One recommendation included the expansion of educational programs dedicated to quality and safety. We subsequently implemented a quality and safety culture education program (Q-SCEP) in our large radiation oncology department. The purpose of this study is to describe the design, implementation, and impact of this Q-SCEP. METHODS AND MATERIALS: In 2010, we instituted a comprehensive Q-SCEP, consisting of a longitudinal series of lectures, meetings, and interactive workshops. Participation was mandatory for all department members across all network locations. Electronic surveys were administered to assess employee engagement, knowledge retention, preferred learning styles, and the program's overall impact. The Agency for Healthcare Research and Quality (AHRQ) Survey on Patient Safety Culture was administered. Analysis of variance was used for statistical analysis. RESULTS: Between 2010 and 2015, 100% of targeted staff participated in Q-SCEP. Thirty-three percent (132 of 400) and 30% (136 of 450) responded to surveys in 2012 and 2014, respectively. Mean scores improved from 73% to 89% (P < .001), with the largest improvement seen among therapists (+21.7%). The majority strongly agreed that safety culture education was critical to performing their jobs well. CONCLUSIONS: Full course compliance was achieved despite the sizable number of personnel and treatment centers. Periodic assessments demonstrated high knowledge retention, which significantly improved over time in nearly all department divisions. Additionally, our AHRQ patient safety grade remains high and continues to improve. These results will be used to further enhance ongoing internal safety initiatives and to inform future innovative efforts.

Factors associated with event reporting in the pediatric radiation oncology population using an electronic incident reporting system.

PURPOSE: Pediatric patients may receive complex treatment. In our department, an electronic incident reporting system (condition reporting system [CRS]) was developed and made available to all members. METHODS AND MATERIALS: The CRS system is available on all departmental computers. Entered events are evaluated and graded by a supervisor as follows: "A"(dose deviation or patient harm), "B" (near miss), "C" (interruption in care process), or "D" (inconvenience). Data for pediatric patients for whom events were entered were reviewed retrospectively and compared to the entire treated pediatric population. RESULTS: Over 2 years, 503 pediatric patients received radiation therapy (median age 10.1 years; range, 0.5-18.8 years), and 592 pediatric CRS events were entered (9.8% of 6020 total institutional CRS entries). These concerned 275 patients with an average of 2.1 entries each; 59% (348) were graded as severity D, 39% (230) as C, 2% (14) as B, and none as A. Events were most commonly related to treatment process (32%, n = 188), followed by planning/dosimetry (19%, n = 109), anesthesia (15%, n = 86), scheduling/transport (13%, n = 73), and physics (10%, n = 62). Delays associated with events were ≤1 hour for most cases (83%, n = 474). Patient and treatment factors associated with CRS entry included total duration of radiation therapy, primary brain tumor, receipt of proton therapy, and receipt of double-scattered proton therapy. No significant differences were found based on age, sex, race, treatment intent (curative vs palliative), type of photon treatment (conformal vs intensity modulated radiation therapy vs arc), use of total body irradiation, or use of pencil beam scanning proton therapy. CONCLUSIONS: An incident reporting system is a widely used part of the safety culture at our institution, which treats one of the largest pediatric patient volumes in North America. Most pediatric CRS-reported events are of minor severity. Longer treatment course and use of new and complex technologies appear to increase the likelihood of a CRS event within the pediatric population, which supports the need for increased safety processes when new techniques are initiated.

Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.

BACKGROUND: Incident learning programs have been recognized as cornerstones of safety and quality assurance in so-called high reliability organizations in industries such as aviation and nuclear power. High reliability organizations are distinguished by their drive to continuously identify and proactively address a broad spectrum of latent safety issues. Many radiation oncology institutions have reported on their experience in tracking and analyzing adverse events and near misses but few have incorporated the principles of high reliability into their programs. Most programs have focused on the reporting and retrospective analysis of a relatively small number of significant adverse events and near misses. To advance a large, multisite radiation oncology department toward high reliability, a comprehensive, cost-effective, electronic condition reporting program was launched to enable the identification of a broad spectrum of latent system failures, which would then be addressed through a continuous quality improvement process. METHODS: A comprehensive program, including policies, work flows, and information system, was designed and implemented, with use of a low reporting threshold to focus on precursors to adverse events. RESULTS: In a 46-month period from March 2011 through December 2014, a total of 8,504 conditions (average, 185 per month, 1 per patient treated, 3.9 per 100 fractions [individual treatments]) were reported. Some 77.9% of clinical staff members reported at least 1 condition. Ninety-eight percent of conditions were classified in the lowest two of four severity levels, providing the opportunity to address conditions before they contribute to adverse events. CONCLUSIONS: Results after approximately four years show excellent employee engagement, a sustained rate of reporting, and a focus on low-level issues leading to proactive quality improvement interventions.