Common error pathways seen in the RO-ILS data that demonstrate opportunities for improving treatment safety.

PURPOSE: The Radiation Oncology Incident Learning System (RO-ILS) receives event reports from facilities across the country. This effort extracted common error pathways seen in the data. These pathways, expressed as fault trees, demonstrate the need for, and opportunities for, preventing these errors and/or limiting their propagation to treatment. METHODS AND MATERIALS: As of the third quarter of 2016, 2344 event reports had been submitted to RO-ILS and reviewed. A total of 396 of the reports judged highest priority were rereviewed and assigned up to 3 keywords to classify events. Based on patterns among the keyword assignments, the data were further aggregated into pathways leading to 3 general error types: "problematic plan approved for treatment," "wrong shift instructions given to therapists," and "wrong shift performed at treatment." Fault trees were created showing how different errors at different stages in the treatment process combine to flow into these general error types. RESULTS: A total of 173 of the 396 (44%) events were characterized as belonging to 1 of these 3 general error types. Ninety-nine events were defined as "problematic plan approved for treatment," 40 as "wrong shift instructions given to therapists," and 34 as "wrong shift performed at treatment." Seventy-six of these events (44%) resulted in incorrectly delivered treatment. Event discovery was by therapists (n = 76), physicists (n = 45), physicians (n = 23), dosimetrists (n = 15), or not identified (n = 9); 5 events were found as a result of the patient questioning the staff. For the event type "problematic plan approved for treatment," 64 of the 99 (65%) events were attributable to physician error: incorrect target or dosing pattern prescribed. CONCLUSIONS: Data extracted from RO-ILS event reports demonstrate common error pathways in radiation oncology that propagate all the way to treatment. Additional study and coordination of efforts is needed to develop and share best practices to address the sources of these errors and curtail their propagation.

The rise of reimbursement-based medicine: the case of bone metastasis radiation treatment.

It has been hypothesised that the reimbursement system pertaining to radiotherapy is influencing prescription practices for patients with cancer with bone metastases. In this paper, we present and discuss the results of an empirical study that was undertaken on patient records, referred to radiotherapy for the treatment of bone metastases, in a medium-size city, in southern Brazil, during the period of March 2006 to March 2014. Our findings seem to confirm this hypothesis: after a change in the reimbursement method, radiation prescriptions were adapted accordingly, in order to maximise profits. Once such patients become highly vulnerable due to their diagnoses, they also become susceptible to a subtle form of exploitation; physicians let patients believe that more radiation will be better for their health, and they do so despite knowing otherwise, and as it seems, out of pecuniary interests.

[The future of radiation oncology: technology, ethical considerations and economical aspects]. / La radio-oncologie de demain: comment concilier l'éthique, le développement technique et les aspects économiques?

We are facing a real technical revolution in radiation oncology. The radiation oncologist is pushed by the industry to implement rapidly new and "high-tech" therapeutic modalities. All of the technical improvements are obviously aiming at an increase in the therapeutic index. However, one should be cautious before implementing on a large scale those technical innovations as no one really knows neither what the possible impact is on medical outcome (efficacy, toxicity and risk), nor what the economical consequences will be. It is our duty as radiation oncologists to make a comprehensive estimation of the impacts in order to be able to set up guidelines for use that are both ethical and in respectful of human dignity.

Should an academic radiation oncologist be allowed to "opt out" of medicare?

Federal law permits physicians to "opt out" of Medicare. When a radiation oncologist chooses this option, he or she may neither bill nor collect from Medicare, but may legally attempt to charge and collect what he or she considers the value of services provided to Medicare-eligible patients. Many academic faculty practice plans permit members to opt out. Even if it is permissible for a radiation oncologist to opt out of Medicare, is it appropriate? The question raises significant ethical and economic issues as one attempts to balance the good of the individual faculty member against the good of the clinical faculty as a whole. In this commentary, the authors offer the principal arguments in favor of and against permitting a faculty radiation oncologist to opt out. They conclude by recommending broad faculty oversight over such decisions.