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Practical risk management methods in healthcareA description of prospective and retrospective risk management tools
Joanne CunninghamTrinity College Dublinsnichuin@tcd.ie
J CunninghamESTRO Lisbon
REQUIRED: A Mechanic with Experience
URGENT!
The Systems Approach
“We cannot change the human condition, but we can change the conditions under which humans work” James Reason
“Every system is perfectly designed to achieve the results it achieves”
Donald Berwick
Radiation Oncology Practice Standards (Tripartite Agreement)
Outline
Identifying Risk Prospective and Retrospective “Identification of safety issues and
concerns”
Quantifying Risk Managing Risk
RO Literature
Identifying RISK
Number of methods & techniques exist Combination required
Methods & techniques should be appropriate to expected risk e.g. flow chart for process
Ongoing programme Method should be financially sound Collaboration with other members of dept
IMAGINATION . . . EXPERIENCE . . .OPENNESS
Methods to identify risk
Desk-based vs Site-visits / Walk-arounds Quantitative vs Qualitative Broad areas of risk vs Specific risks Top-down vs Bottom-up approach Retrospective vs Prospective
All perspectives and possibilities
Know your enemy!
The key questions in identification of risk are: What can go wrong? How can it go wrong? How frequently can it go wrong? What would be the outcome?
Risk Assessment
ESTRO Lisbon
J Cunningham
Sometimes, staring you in the face...
ESTRO Lisbon
J Cunningham
Somenot so visible!
ESTRO Lisbon
J Cunningham
Some Prospective Techniques of Risk Identification
Risk surveys and audits, involving: Structured observation / Physical inspection Risk audit Checklists Interviews Questionnaires
Flow charts / Process Trees / Mapping Analytical Trees
Organisational Charts Project Evaluation Trees Fault Tree analysis
FMEA (Failure Mode Effects Analysis) HAZOP Studies (Hazard and Operability Studies)
Identify Broad Areas of Risk
Identify Specific Risks
Some Retrospective Techniques of Risk Identification
Root Cause Analysis (prospective = Fault Tree Analysis)
Events and Causal Factors Analysis = ECFA Sequential Timed Events Plotting = STEP Man Technology Organisation = MTO
Incident reporting and incident investigation
Prospective Techniques of Risk Identification
Flow Charts
Process Trees
Failure Modes Effects Analysis (FMEA)
- Dr James
MacKean
Analytical Trees
Fault Trees (FTA)
HDR Process TreeAdapted from Thomadsen et al IJROBP 2003;57(5):1492-1508
Procedures leading to an
HDR Brachytherapy
treatment
QA
on
unit
Cal
ibra
tion
Successful Treatment
Del
iver
y
Dos
e/tim
e C
alcu
latio
n
Rec
onst
ruct
ion
App
licat
ion
Rec
ordi
ng
Prog
ram
min
g
Plan
ning
QA
Opt
imis
atio
n
Loca
lisat
ion
37568
141
5 35
0-4
5-9
10-19
20-29
30+
“Level 2 & 3”
TreatmentDelivery
Patient ID RT Setup
Pt Position
Accessories
Dose
Bolus
Wedge
Compensator
Shielding
Field omitted
Fld re-treatedOrientation
Field size
Collimator Angle
Gantry Angle
SSD/FSD
Isocentre
Couch height
Unobstructed field
# Missed
PositioningAids
TBI Screen
Couch angle
Extra #
Energy
Undefined
Field omitted, field re-treated
Undefined
Dose
LEVELS 2 AND 3
Prospective Techniques of Risk Identification
Flow Charts Process Trees
FMEA HAZOP Analytical Trees
Fault Trees
Analytical Trees “Pictures of a project” Top event defined and deductive reasoning
used to develop down through the branches to specific input events
Positive Trees (Objective trees) Developed to make sure that a system works
properly Planning tools, graphic checklists, project
description “Feeder Documents” for many types of hazard
analysis e.g. FMEA Negative Trees (Fault trees)
Used for troubleshooting and To investigate system failures
Analytical Trees
Analytical Trees Displays clear thinking Forces use of deductive analysis and to think
about events that must occur at lower levels for output events to be generated
Show how relationships and interfaces occur Identifies critical paths Serve as checklists once completed Identify root causes if used for accident
analysis
Fault tree analysis (FTA)
FTA is a deductive, top-down method of analyzing system design and performance Quantify risk Trace causes Calculate sensitivity to changes in system
It involves specifying a top event to analyze, followed by identifying all of the associated elements in the system that could cause that top event to occur
Fault Tree Symbols
From: Systems Safety for the 21st Century. R A Stephens. Figure 15.5
From: Systems Safety for the 21st Century. R A Stephens. Figure 15.5
Reliability / Failure Probability
AND Gate: Multiply probabilities of input events under an AND gate to calculate probability of the output event.
OR Gate: Add probabilities of input events and subtract probabilities of combinations
PA= PB+PC+PD-PBPC-PCPD-PBPD+PBPCPD
If “P”s <0.1, use PA=PB+PC+PDPA=PBPCPD
From: Systems Safety for the 21st Century. R A Stephens.
R = 0.99+0.99–(0.99x0.99) = 0.9999
FP = 0.01 x 0.01 = 0.0001
0.9999 0.0001
From: Systems Safety for the 21st Century. R A Stephens.
Reliability = 0.9x0.99x0.999x0.9999x0.9999 = 0.8899 = 0.89
R = 0.99+0.99–(0.99x0.99) = 0.9999
FP = 0.01 x 0.01 = 0.0001
Failure Probability = 0.1+0.01+0.001+0.0001+0.0001 = 0.1112 = 0.11
0.9999 0.0001
Light 1
Light 2
Light 1
Light 2
Reliability=0.9x0.99x0.999x0.9999x0.99x0.99 = 0.8723 = 0.87
Failure Probability=0.1+0.01+0.001+0.0001+0.01+0.01 = 0.1311 = 0.13
Light 1
Light 2
Reliability = 0.87
Failure Prob. = 0.13
Reliability = 0.89
Failure Prob. = 0.11
Comparison of Options
J Cunningham
Some error producing conditions ranked in order of known effect
Adapted from Vincent C. Clinical Risk Management. 2nd Ed. 2001
Condition Risk factor
Unfamiliarity with the task x 17
Time shortage x 11
Poor human:system interface x 8
Information overload x 8
Misperception of risk x 4
Inexperience - not lack of training x 3
Poor instructions or procedures x 3
Inadequate checking x 3
Disturbed sleep patterns x 1.6
Monotony and boredom x 1.1
Estimates of Human Performance Error Rates Systems Safety for the 21st Century. R A Stephens
General error of omission (no control
room display)
Upper limit to
credibility
Two-man team (one do; one check, then
reverse roles)
Technician “seeing” an out of calibration
instrument as “in tolerance”
Monitor/inspector fails to recognise
initial error by operator
Simple arithmetic errors (without re-
doing calculation on separate paper)
General errors of commission e.g.
misread label and selected wrong switch
100 10-1 10-2 10-3 10-4 10-5 10-6
1 in 101 in 1 1 in 100 1 in 1000 1 in 10000 1 in 100000 1 in 1000000
Fault Trees
Quantification of risk: sources of probabilities: Industry-wide figures Manufacturers (esp failure of
equipment) Employees / experts (subjective) Previous experience at organisation
Fault tree analysis (FTA)
FTA is a deductive, top-down method of analyzing system design and performance Quantify risk Trace causes Calculate sensitivity to changes in system Helps to identify where to put barriers and checks
Disadvantages Time expensive Accuracy relies on accuracy of probabilities
given to events
Industry ------------------Medicine
“In industries such as nuclear power, where probabilistic risk assessment originated, most failures occur only when several systems fail concurrently, and the combination of probabilities becomes important. Most medical events, although they have several root causes and concurrent unusual situations, fail along a single branch of the fault tree”
Thomadsen & Li; IJROBP 2003;57(5):1492-1507
Retrospective Techniques of Risk Identification
RCA – (FTA as for prospective)
ECFA STEP MTO
Incident reporting and investigation
Root Cause Analysis Julie Miller The Radiographer 51;19-22
Facilitator Understanding of RCA Conducts interviews Prepares table of normal process compared with incident process
Team of 6-8 people 1 from outside RT 1 position of authority in RT at least 2 persons involved in incident Clinician (ideally treating patient)
First Meeting third column is added to the table, in which the reason for any variance
is recorded BUT no attempt to analyse the variance occurs Second Meeting
analysis of the variations occurs and recommendations for changes in processes are made, with deadlines and responsible persons
Root Cause Analysis Stephen Sutlief, AAPM 2010
Simple Framework for RCA Chronological sequence
Diagram the flow of events leading up to the incident (including the three “whys”) Ask why each event occurred until there are no more questions (or no more answers)
Cause and Effect Diagramming Identify the conditions that resulted in the adverse event or close call
Causal Statements Develop root cause and contributing factor statements, actions, and outcomes
The Three WhysWhen distilling the event narrative into an event flow diagram, it is useful to ask the three whys:
What happened? Why did it happen? What are you going to do about it?
An expert in the 5 whys! “Why did they build
the Great Ocean Road so wibbly-wobbly?”
...Why? ...Why? ...Why? ...BUT WHY?
Root Cause Analysis Stephen Sutlief, AAPM 2010
The Five Rules of Causation: Clearly show the cause and effect relationship Use specific descriptors, not vague words Identify preceding causes, not human error Identify preceding causes of procedure violations Failure to act is only casual when there is a pre-existing
duty to act
Dosimetry error
Dose calculation error
Source strength error
Wrong data (decay factor)
Wrong calibrationWrong source data
Failure of verification
Incorrect entryErreneous strength
for source dataWrong data (US vs
EU format)Failure of
verificationCalibration
error
Wrong units
Measurement error
Calculation error
Failure to enter or alter
data
Wrong source in device
Error in data entry
Discrepancy in strength between device and planning
system
FTA exampleAdapted from Thomadsen and Li
by T Knoos
Dose calculation error
Software error
Incompatible factors for
caclibration and dose calculation
Wrong patient’s
data used
Incorrect data entry
Dose specification
to wrong points
Wrong or incompatible
units
Incorrect data
transfer
Wrong dose
Wrong location of dose
distribution
Wrong dwell positions activated
Incorrect dwell times
entered
Incosistent step size
Incorrect shape of
dose distribution
Corrupt file
Software version
incompatibility
Algorithm error
Error in specification
Incorrect marker
Marker in wrong position
Inappropriate marker
Entry error
QM failure
Inaccurate source
position entry
Physicians’s error
Incorrect entry
Interpretation error
Physicians’s error
Wrong chart referenced
Data transposition
Error in transfer
FTA exampleAdapted from Thomadsen and Li
by T Knoos
Retrospective Techniques of Risk Identification
RCA – (FTA as for prospective)
ECFA Events and Causal Factors Analysis
STEP Sequential Timed Events Plotting
MTO Man Technology and Organisation Analysis
Incident reporting and investigation
ECFA - Events and Conditional1 Factors Analysis
3 main purposes in investigations Verification of causal chains and
event sequences Provides a structure for integrating
investigation findings Assists in communication both during
and on completion of the investigation
Typical ECFA work team using PostIt and a White
board
1The word Cause is used just as often as Conditional
ECFA
Practical guidelines for investigating an accident Begin early Use the guidelines Proceed logically with available
data. Use an easily updated format Correlate use of ECFA with that of
other MORT investigative tools Select the appropriate level of
detail and sequence length Make a short executive summary
chart when necessary
Typical ECFA work team using PostIt and a White
board
Events and Causal Factors Analysis
EventsWhat, When, Who
Influences Causal Factors
Events and Causal Factors Analysis
Definite
Unconfirmed
Causal Factor
Event 1 Event 2 Event 3
Causal Factor
Example ECFA: ROSIS Report 25Event: treated on incorrect isocentreDiscovered: When went to treat posterior field Description: RAO Lt Axilla field (8.8cm x 7cm) was treated with the Ant
Medial forearm prescription (5.5cm x 2cm). Both fields were 6MV energy and prescribed for 1Gy/field/fraction. There was no indication of what fields were for which target – all fields were displayed equally in the same box, with nothing to distinguish a field for Target 1 from a field for Target 2.
Causes:R&V Fields not adequately named for two targets e.g Rt Ant Obliq, RAO2, Ant Field names not fully visible on screenSet-up instructions did not specify 2 targets / alert staff to fact that there was 2
targetsMachine breakdown – treated on different machine with staff not familiar with
set-up or patientDifficult patient (v. impatient & excitable child, 7 y.o.)Unusual and heavy workload and stressful situation (machine breakdown)Excess staff (6-7 vs 4-5)Fields treated in different sequence to normalInsufficient staff communicationResponse/Suggestion: Field names were changed to reflect targets
Systemic condtions
Contributing factors
Contributing factors
Primary events
Systemic condtions
Systemic factors
Treatment unit broke down
Patient changed
treatment unit
Patient positioned on
couchBeam selected
Beam positioned incorrectly
Treated wrong target/isocenter
Complicated setup
Too many staff
Heavy workload
Management or supervisor
failure
Field names confusing
Field/target connection
missing
R/V design flaw
Patient difficult
Unclear setup
instructions
Lack of equipment
Beam positioned incorrectly
Lack of communication
Staff not familiar w
patient
Observation failure
Retrospective Techniques of Risk Identification
RCA – (FTA as for prospective)
ECFA Events and Causal Factors Analysis
STEP Sequential Timed Events Plotting
MTO Man Technology and Organisation Analysis
Incident reporting and investigation
MTO – Man, Technology and Organisation analysis
Using event and cause diagram
Describing how events have deviated from praxis
Barrier analysis by identifying technological and organisational barriers that have failed
MTO analysis worksheet
Causes
Events
DeviationNormal
Ba
rrie
r a
na
lysis
Ba
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r a
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Eve
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an
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Ch
an
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an
aly
sis
MTO analysis worksheet
Causes
Events
DeviationNormal
Ba
rrie
r a
na
lysis
Ba
rrie
r a
na
lysis
Eve
nts
an
d c
au
se
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se
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ha
ng
e a
na
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Ch
an
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an
aly
sis
Start with the chain of events in the process
MTO analysis worksheet
Causes
Events
DeviationNormal
Ba
rrie
r a
na
lysis
Ba
rrie
r a
na
lysis
Eve
nts
an
d c
au
se
sE
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nts
an
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au
se
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ha
ng
e a
na
lysis
Ch
an
ge
an
aly
sis
Add the cause resulting in each event
MTO analysis worksheet
Causes
Events
DeviationNormal
Ba
rrie
r a
na
lysis
Ba
rrie
r a
na
lysis
Eve
nts
an
d c
au
se
sE
ve
nts
an
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au
se
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ha
ng
e a
na
lysis
Ch
an
ge
an
aly
sis
Identify the events that went wrong, and add these causes that led to the failure
MTO analysis worksheet
Causes
Events
DeviationNormal
Ba
rrie
r a
na
lysis
Ba
rrie
r a
na
lysis
Eve
nts
an
d c
au
se
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Ch
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aly
sis
Add the barriers that actually failed or was missing during the accident or incident
The final step is to identify and present actions to avoid a new occurrence
Investigation tools/methods
Sequencing tools Events and Conditional Factors Analysis - ECFA Sequential timed events plotting - STEP
Hypothesis tools Fault Tree Analysis – FTA Man, Technology and Organisation analysis –
MTO Failure Modes and Effects Analysis – FMEA Hazard And OPerability study - HAZOP
Identifying RISK - Summary
Number of methods & techniques exist Combination required
Methods & techniques should be appropriate to expected risk e.g. flow chart for process
Ongoing programme Method should be financially sound Collaboration with other members of dept
IMAGINATION . . . EXPERIENCE . . .OPENNESS
RISK ASSESSMENT
/ Risk Evaluation / Risk Ranking / Risk Rating / Risk Scoring . . .
How Thin?
Quantifying risk
Bryan O’Connor, former astronaut
“We fooled ourselves into thinking this thing wouldn’t crash. When I was in astronaut training I asked ‘what is the likelihood of another accident?’ The answer I got was: 1 in 10,000*. The ‘*’ meant: ‘we don’t know’.”
Jan 10 1996; Space News interview
Risk Assessment
Different methods in use – likelihood x severity; likelihood x detection x severity; (type + severity) x likelihood x number
affected
Relies on historical data to predict future events
Likelihood of Recurrence
Outcome and Scope
Critical 5
Major 4
Moderate 3
Minor 2
Trivial 1
Certain
5
5x5
5x4
5x3
5x2
5x1
Very Likely
4
4x5
4x4
4x3
4x2
4x1
Possible
3
3x5
3x4
3x3
3x2
3x1
Unlikely
2
2x5
2x4
2x3
2x2
1x2
Highly Unlikely
1
1x5
1x4
1x3
1x2
1x1
Very
High Risk
High Risk
Medium Risk
Low Risk
RISK CONTROL
Risk Control
Hierarchy of Actions: Elimination Substitution Engineering controls or safety measures Administrative controls which reduce or
eliminate exposure to a hazard by adherence to procedures or instruction
Personal Protective Equipment (PPE)
Health and Safety Authority; Ireland
Defence in Depth
MOST Effective
LEAST Effective
For Radiation Oncology...
Automation, standardization, checklists, redundancy
Human Factors in the design of products and workspaces
Safety Culture
Safety is no accident
https://www.astro.org/uploadedFiles/Main_Site/Clinical_Practice/Patient_Safety/Blue_Book/SafetyisnoAccident.pdf
Simple, everyday ideas for improving quality and safety
Reason’s Model of Organisational Accidents
Management Decision
Organisational Process
Latent Failures
Background conditions:
• Workload • Supervision • Communication •Training/ knowledge/ ability• Equipment
Conditions of Work (current)
Unsafe Acts:
• Omissions• Action slips / failures• Cognitive failures (mistakes and memory lapses)• Violations
Active Failures
Multilayered Defences
Recognise hazards
ALWAYS be on the lookout - Work with Awareness
Anticipate problems
Learn from Failures
Further Reading:1. DeRosier J, Stalhandske E, Bagian JP, Nudell T: Using health care Failure Mode and Effect Analysis: the VA National Center for Patient Safety's prospective
risk analysis system. The Joint Commission journal on quality improvement 2002, 28(5):248-267, 209.2. Dunscombe PB, Ekaette EU, Lee RC, Cooke DL: Taxonometric Applications in Radiotherapy Incident Analysis. International Journal of Radiation Oncology Biology
Physics 2008, 71(1 SUPPL.).3. Ekaette EU, Lee RC, Cooke DL, Kelly K-L, Dunscombe PB: Risk analysis in radiation treatment: Application of a new taxonomic structure. Radiotherapy and
Oncology 2006, 80(3):282-287.4. Ekaette E, Lee RC, Cooke DL, Iftody S, Craighead P: Probabilistic Fault Tree Analysis of a Radiation Treatment System. Risk Analysis 2007, 27(6):1395-1410.5. Govindarajan R, Molero J, Tuset V, Arellano A, Ballester R, Cardenal J, Caro M, Fernández J, Jové J, Luguera E et al: Failure Mode and Effects Analysis (FMEA)
helps improve safety in radiation therapy. El análisis modal de fallos y efectos (AMFE) ayuda a aumentar la seguridad en radioterapia 2007, 22(6):299-309.6. Hamilton C, Oliver L, Coulter K: How safe is Australian radiotherapy? Australasian Radiology 2003, 47(4):428-433.7. Huq MS, Fraass BA, Dunscombe PB, Gibbons Jr JP, Ibbott GS, Medin PM, Mundt A, Mutic S, Palta JR, Thomadsen BR et al: A Method for Evaluating Quality Assurance
Needs in Radiation Therapy. International Journal of Radiation Oncology Biology Physics 2008, 71(1 SUPPL.).8. Israelski EW, Muto WH: Human factors risk management as a way to improve medical device safety: a case study of the therac 25 radiation therapy
system. Jt Comm J Qual Saf 2004, 30(12):689-695.9. Kapur A, Potters L: Six sigma tools for a patient safety-oriented, quality-checklist driven radiation medicine department . Practical Radiation Oncology
2012, 2(2):86-96.10. Lee R, Kelly K-L, Newcomb C, Cooke D, Ekaette E, Craighead P, Dunscombe P: Quantitative Approaches to Patient Safety: Research in Risk Analysis and Risk
Management as Applied to Radiotherapy. HTA Initiative #15 Alberta Heritage Fund for Medical Research 2004.11. Lucà F, Fileni A: Risk management in radiotherapy: Analysis of insurance claims. La gestione del rischio in radioterapia: Analisi del contenzioso assicurativo
2006, 111(5):733-740.12. Munro AJ: Hidden danger, obvious opportunity: Error and risk in the management of cancer. British Journal of Radiology 2007, 80(960):955-966.13. Nakajima K, Kurata Y, Takeda H: A web-based incident reporting system and multidisciplinary collaborative projects for patient safety in a Japanese
hospital. Quality and Safety in Health Care 2005, 14(2):123-129.14. Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH: Rates and types of events reported to established incident reporting systems in two US hospitals .
Quality and Safety in Health Care 2007, 16(3):164-168.15. Olson AC, Wegner RE, Scicutella C, Heron DE, Greenberger JS, Huq MS, Bednarz G, Flickinger JC: Quality Assurance Analysis of a Large Multicenter Practice:
Does Increased Complexity of Intensity-Modulated Radiotherapy Lead to Increased Error Frequency? International Journal of Radiation Oncology*Biology*Physics 2012, 82(1):e77-e82.
16. Ostrom LT, Rathbun P, Cumberlin R, Horton J, Gastorf R, Leahy TJ: Lessons learned from investigations of therapy misadministration events. International Journal of Radiation Oncology Biology Physics 1996, 34(1):227-234.
17. Patton GA: In regard to Thomadsen et al.: Analysis of treatment delivery errors in brachytherapy using formal risk analysis techniques (Int J Radiat Oncol Biol Phys 2003;57:1492-1508). Int J Radiat Oncol Biol Phys 2004, 59(3):915; author reply 915-916.
18. Peiffert D, Simon JM, Eschwege F: Épinal radiotherapy accident: passed, present, future. L'accident d'Épinal : passé, présent, avenir 2007, 11(6-7):309-312.
19. Peter BD, Edidiong UE, Robert CL, David LC: Taxonometric Applications in Radiotherapy Incident Analysis. International Journal of Radiation Oncology, Biology, Physics 2008, 71(1):S200-S203.
20. Potters L, Kapur A: Implementation of a “No Fly” safety culture in a multicenter radiation medicine department . Practical Radiation Oncology 2012, 2(1):18-26.
21. Rath F: Tools for Developing a Quality Management Program: Proactive Tools (Process Mapping, Value Stream Mapping, Fault Tree Analysis, and Failure Mode and Effects Analysis). International Journal of Radiation Oncology Biology Physics 2008, 71(1 SUPPL.).
22. Scorsetti M, Signori C, Lattuada P, Urso G, Bignardi M, Navarria P, Castiglioni S, Mancosu P, Trucco P: Applying failure mode effects and criticality analysis in radiotherapy: Lessons learned and perspectives of enhancement. Radiotherapy and Oncology 2010, 94(3):367-374.
23. Thomadsen B, Lin SW, Laemmrich P, Waller T, Cheng A, Caldwell B, Rankin R, Stitt J: Analysis of treatment delivery errors in brachytherapy using formal risk analysis techniques. Int J Radiat Oncol Biol Phys 2003, 57(5):1492-1508.
24. Williams MV: Improving patient safety in radiotherapy by learning from near misses, incidents and errors . British Journal of Radiology 2007, 80(953):297-301.
Eric C. Ford, Ray Gaudette, Lee Myers, Bruce Vanderver, Lilly Engineer, Richard Zellars, Danny Y. Song, John Wong, Theodore L. DeWeese, Evaluation of Safety in a Radiation Oncology Setting Using Failure Mode and Effects Analysis, International Journal of Radiation Oncology*Biology*Physics, Volume 74, Issue 3, 1 July 2009, Pages 852-858
Julian R. Perks, Sinisa Stanic, Robin L. Stern, Barbara Henk, Marsha S. Nelson, Rick D. Harse, Mathew Mathai, James A. Purdy, Richard K. Valicenti, Allan D. Siefkin, Allen M. Chen, Failure Mode and Effect Analysis for Delivery of Lung Stereotactic Body Radiation Therapy, International Journal of Radiation Oncology*Biology*Physics, Volume 83, Issue 4, 15 July 2012, Pages 1324-1329
Mario Ciocca, Marie-Claire Cantone, Ivan Veronese, Federica Cattani, Guido Pedroli, Silvia Molinelli, Viviana Vitolo, Roberto Orecchia, Application of Failure Mode and Effects Analysis to Intraoperative Radiation Therapy Using Mobile Electron Linear Accelerators, International Journal of Radiation Oncology*Biology*Physics, Volume 82, Issue 2, 1 February 2012, Pages e305-e311
Danielle N. Margalit, Yu-Hui Chen, Paul J. Catalano, Kenneth Heckman, Todd Vivenzio, Kristopher Nissen, Luciant D. Wolfsberger, Robert A. Cormack, Peter Mauch, Andrea K. Ng, Technological Advancements and Error Rates in Radiation Therapy Delivery, International Journal of Radiation Oncology*Biology*Physics, Volume 81, Issue 4, 15 November 2011, Pages e673-e679
Lakshmi Santanam, Ryan S. Brame, Andrew Lindsey, Todd Dewees, Jon Danieley, Jason Labrash, Parag Parikh, Jeffrey Bradley, Imran Zoberi, Jeff Michalski, Sasa Mutic, Eliminating Inconsistencies in Simulation and Treatment Planning Orders in Radiation Therapy, International Journal of Radiation Oncology*Biology*Physics, Available online 8 May 2012
Anthony Arnold, Geoff P. Delaney, Lynette Cassapi, Michael Barton, The Use of Categorized Time-Trend Reporting of Radiation Oncology Incidents: A Proactive Analytical Approach to Improving Quality and Safety Over Time, International Journal of Radiation Oncology*Biology*Physics, Volume 78, Issue 5, 1 December 2010, Pages 1548-1554
Frank Rath, Tools for Developing a Quality Management Program: Proactive Tools (Process Mapping, Value Stream Mapping, Fault Tree Analysis, and Failure Mode and Effects Analysis), International Journal of Radiation Oncology*Biology*Physics, Volume 71, Issue 1, Supplement, 1 May 2008, Pages S187-S190
Lawrence B. Marks, Christopher M. Rose, James A. Hayman, Timothy R. Williams, The Need for Physician Leadership in Creating a Culture of Safety, International Journal of Radiation Oncology*Biology*Physics, Volume 79, Issue 5, 1 April 2011, Pages 1287-1289
Yaacov Richard Lawrence, Michal A. Whiton, Zvi Symon, Evan J. Wuthrick, Laura Doyle, Amy S. Harrison, Adam P. Dicker, Quality Assurance Peer Review Chart Rounds in 2011: A Survey of Academic Institutions in the United States, International Journal of Radiation Oncology*Biology*Physics, Volume 84, Issue 3, 1 November 2012, Pages 590-595
Eric E. Klein, Balancing the Evolution of Radiotherapy Quality Assurance: In Reference to Ford et al., International Journal of Radiation Oncology*Biology*Physics, Volume 74, Issue 3, 1 July 2009, Pages 664-666
Eric C. Ford, Stephanie Terezakis, How Safe Is Safe? Risk in Radiotherapy, International Journal of Radiation Oncology*Biology*Physics, Volume 78, Issue 2, 1 October 2010, Pages 321-322
Steven J Goetsch, Risk analysis of Leksell Gamma Knife Model C with automatic positioning system, International Journal of Radiation Oncology*Biology*Physics, Volume 52, Issue 3, 1 March 2002, Pages 869-877
System Safety for the 21st Century; Richard A. Stephens. Wiley Interscience, New Jersey; 2004. Risk Analysis, Assessment and Management; Jake Ansell and Frank Wharton; Wiley, London; 1992.VA Health Care Failure Mode and Effects Analysis HFMEA™ - available at:
http://www.patientsafety.gov/SafetyTopics/HFMEA/HFMEA_JQI.pdf
AbstractPurpose: The safe delivery of radiation therapy requires multiple disciplines and interactions toperform flawlessly for each patient. Because treatment is individualized and every aspect of thepatient's care is unique, it is difficult to regiment a delivery process that works flawlessly. Thepurpose of this study is to describe one safety-directed component of our quality program called the“No Fly Policy” (NFP).Methods and Materials: Our quality assurance program for radiation therapy reviewed the entireprocess of care prior, during, and after a patient's treatment course. Each component of care wasbroken down and rebuilt within a matrix of multidisciplinary safety quality checklists (QCL).The QCL process map was subsequently streamlined with revised task due dates and stoppingrules. The NFP was introduced to place a holding pattern on treatment initiation pendingreconciliation of associated stopping events. The NFP was introduced in a pilot phase using aSix-Sigma process improvement approach. Quantitative analysis on the performance of the newQCLs was performed using crystal reports in the Oncology Information Systems. Root causeanalysis was conducted..
Safety is no accident A FRAMEWORK FORQUALITY RADIATIONONCOLOGY AND CARE – ASTRO et al
INGRAINING SAFETY INTO EVERYDAY PRACTICE
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