Evan Charles Osmundson MD, PhD, Presenter: Nothing to Disclose

Tiffany M. Symmes, Abstract Co-Author: Nothing to Disclose

Karl Bush PhD, Abstract Co-Author: Nothing to Disclose

Todd F. Atwood PhD, Abstract Co-Author: Nothing to Disclose

Brian Chhor, Abstract Co-Author: Nothing to Disclose

Michelle Kenyon, Abstract Co-Author: Nothing to Disclose

Lynn Million MD, Abstract Co-Author: Nothing to Disclose

Albert C. Koong MD, PhD, Abstract Co-Author: Nothing to Disclose

Modern radiotherapy treatment planning and delivery is a complex process involving multiple medical personnel and the transfer of critical data within organizational systems at risk for errors. In Dec 2012, the error reporting and quality assurance (QA) program at a major academic radiation oncology department was comprehensively updated to gather personnel- and systems-related data (Radiation Oncology Quality and Safety (ROQS) system). The objective of our study was to assess the utility of the ROQS system for determining logistical risk factors associated with reported errors.

ROQS-reportable events are captured using a secure web-based form accessible to all departmental staff. A ROQS committee comprised of clinical and management personnel meet semi-monthly to classify events and guide quality improvement efforts. Problem solving initiatives are implemented as a result of events reported, as appropriate. Events are classified into 3 major categories as actual events (A class), near misses (B class), or workflow-related events (C class), and are then subclassified according to the severity of the event or potential for harm if a near miss (e.g. A1-A3 events correspond to aberrations in dose delivered with dose differences ≥20%, 5% to 20%, and <5% respectively). Reported events were assessed for their relationship to logistic and treatment-related variables.

31,309 treatments were delivered from Dec 2012 - Nov 2013. During this period, 7 class A and 23 class B events were reported (0.2235/1000 and 0.7346 /1000 treatments respectively). No A1 or A2 events or events leading to major patient harm were observed. Among linac-treated patients with complete data available for assessment (n= 1452), class A events were significantly associated with a simulation to treatment time of less than 7 days (RR 4.98, p=0.019).

The ROQS system is a comprehensive QA approach designed to capture organizational and procedural factors contributing to errors. Data obtained from the ROQS system can be used to specifically target quality improvement efforts within a complex radiation therapy delivery system.

Targeted workflow changes designed to address logistical risk factors identified by the ROQS system are predicted to decrease error rates and improve the safety of patients undergoing radiotherapy.

Osmundson, E, Symmes, T, Bush, K, Atwood, T, Chhor, B, Kenyon, M, Million, L, Koong, A, ROQS: A Comprehensive Error Reporting and Quality Assurance Program for Radiation Oncology.  Radiological Society of North America 2014 Scientific Assembly and Annual Meeting, - ,Chicago IL. http://archive.rsna.org/2014/14016934.html