The inaugural issue of a new journal Practical Radiation Oncology published by ASTRO (the American Society for Radiation Oncology) highlights patient safety issues in the field. In early 2010 we did several columns on radiation safety issues after the NY Times publication of its eye-opening 2-part series (Bogdanich 2010a and 2010b) on the hazards of radiation (see our February 2, 2010 Patient Safety Tip of the Week “The Hazards of Radiation” and our March 2010 What’s New in the Patient Safety World column “More on Radiation Safety”).
In response to the multiple concerns raised in the New York Times series, ASTRO and multiple other stakeholder organizations convened a meeting to address patient safety in radiation oncology. That meeting is summarized in one of the papers in the new journal (Hendee 2011). They identified numerous causes and contributing factors to adverse outcomes in radiation oncology. These included not only issues related to the ever-increasing complexity of technology involved but also issues related to the human-technology interface. They noted growing dependence on computerized aspects had led to diminished knowledge and direct control of actual treatment by the radiation therapist. But many more mundane factors are operative as well: cluttered workstations, interruptions, multiple computer screens, lack of warning systems to identify settings outside usual parameters, etc. Added to these were the usual culprits of communication issues and failure to buck the authority gradient. They came up with 20 key recommendations (see the full text of the actual paper for details).
The second paper (Marks 2011) takes a more fundamental FMEA (failure mode and effects analysis) approach and identifies numerous challenges and potential opportunities for errors to occur in radiation oncology. It emphasizes that total error prevention is unlikely and that identification of errors before they cause patient harm should be the most important goal. They do discusss the scant available data reported on radiation oncology incidents (we’ve previously lamented that the biggest database on such incidents was not one put together by any regulatory body but rather the one put together by the New York Times!). They make a case for centralized data repositories to better categorize and analyze errors so that solutions can be widely disseminated. They did recognize that the rapid advancements in technology have caused a shift in the type and frequency of errors. For example, data entry errors have decreased but operator errors have increased. Lack of standardization (eg. often staff are working with multiple different machine types in the same center) becomes an issue, as does the sense of infallibility of the computer. They also note that the rapidly changing technologies have increased time pressures on everyone involved in radiation oncology and recognize that “rush to treat” often spawns error-prone workarounds. Newer technologies allow for much more focused radiation beams. But this also means the radiation units per dose are higher and, if delivered to the wrong tissues, can have serious side effects. Along the same lines, the newer technologies deliver radiation over much shorter time frames. In the past, a dosage error on one day could be compensated by a change in dosage on other days. Not so anymore. Importantly, some of the traditional quality assurance tools of the past are no longer applicable with the newer technologies.
But many of the changing features of the general medical landscape have also contributed. They note the transition from paper to electronic medical records has had an impact that has been at times disruptive to workflows. Some simple things, like drawings, that appeared in paper records have been difficult to replicate in electronic records. And the lack of interconnectivity has resulted in time-consuming double data entry in many cases. The number of handoffs has also increased. All these have added to the complexities of managing radiation therapy and introduced opportunities for error.
They go on with multiple practical recommendations to improve patient safety. Some topics are specific and include staffing, workflow, efficiency (including discussion of “lean” or Toyota Production System techniques), and standardization. But they also cover the more overriding concepts in patient safety such as the importance of developing a culture of safety, using human factors engineering concepts in design of facilities and workflows and equipment, using “huddles”, doing safety rounds, etc. And they stress prioritizing interventions according to the hierarchy of effectiveness (eg. that constraints and forcing functions are much more effective than education and policies).
Whether you and your organization are involved in radiation oncology or whether you are simply interested in patient safety overall, this issue of Practical Radiation Oncology is very worthwhile reading.
Bogdanich W. The Radiation Boom. Radiation Offers New Cures, and Ways to Do Harm. New York Times. January 24, 2010
Bogdanich W. The Radiation Boom. As Technology Surges, Radiation Safeguards Lag.
The New York Times. January 26, 2010
Marks LB, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation oncology. Practical Radiation Oncology 2011; 1(1): 2-14
Hendee WR, Herman MG. Improving patient safety in radiation oncology. Practical Radiation Oncology 2011; 1(1): 16-21