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Complexity Associated with Near Miss or Safety Incidents in Patients Treated with Radiotherapy

TON - May 2017, Vol 10, No 3 - Best Practices
Meg Barbor, MPH

Orlando, FL—Several treatment- and disease-specific factors are associated with near miss or safety incidents (NMSIs) among patients treated with radiotherapy, according to Greg D. Judy, MD, Radiation Oncologist, University of North Carolina Health Care, Chapel Hill.

Patient safety is a vital concern in radiation oncology, and NMSIs are estimated to occur in ≤5% of the >600,000 patients receiving radiotherapy each year. A safety incident is defined as an event that reaches the patient, whereas a near miss does not reach the patient. Retrospective studies have shown associations with patient-, disease-, and treatment-specific factors, but there is still much to learn about contributory factors, he said. The key components for identifying patients at risk for NMSI were the complexity of the treatment plan and the complexity of the overall process, Dr Judy reported at the American Society of Clinical Oncology 2017 Quality Care Symposium.

Complexity Associated with Near Miss or Safety Incidents

Dr Judy and his colleagues conducted a retrospective case-control study of NMSIs filed in the University of North Carolina Event Reporting System between October 2014 and April 2016, and extracted patient-, treatment-, and disease-specific data. The study population was comprised of 200 patients with an NMSI, and 200 patients without an NMSI. The researchers sought to identify common root causes of incidents, as well as any existing relationships with incident severity and differences between the incident and control groups.

Each incident was assigned a root cause from 1 of 5 categories, including documentation, communication, technical treatment planning, technical treatment delivery error, or other. Incidents were also assigned to 1 of 3 categories for severity, including near miss, clinically insignificant (ie, reached the patient but did not affect outcomes or treatment modality), or clinically significant (ie, reached the patient and did affect outcomes or treatment modality).

The researchers found 4 factors that identified patients at higher risk for an NMSI—T2 tumors versus tumors with other T stages, head- and neck-treated sites versus other disease sites, image-guided intensity-modulated radiation therapy versus other treatment modalities, and daily imaging versus no or weekly imaging.

Documentation and scheduling errors were found to be the most common root causes; each occurred in approximately 30% of patients. Communication errors, however, were more likely to affect the patient, by “at least having a clinically insignificant severity,” Dr Judy noted.

“And while not as common, technical treatment delivery was associated with higher severity,” he added.

According to Dr Judy, these results suggest that complexity is a contributing factor for an NMSI.

“This is important to understand because it promotes the idea of developing a more dedicated and robust quality assurance system for complex cases, and highlights the importance of a strong reporting system to support a safety culture and promote continuous learning and improvement efforts,” he said. The investigators plan to conduct a more in-depth analysis of root causes associated with NMSIs.

“Incident learning is becoming more widespread in the field of radiation oncology, and incident reporting systems are an effective strategy for incident learning,” Dr Judy added.

Since its launch in June 2014, >250 facilities across the country have joined a national reporting system known as RO-ILS (Radiation Oncology Incident Learning System). Members contribute to patient safety data, thereby facilitating cooperative research, safety standards, and higher quality care in radiation oncology.

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Last modified: July 22, 2021