• Home

  • Documents

  • Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient...
48
Applying TG-100 Methodology to SRS / SBRT Jennifer Lynn Johnson, MS, MBA Senior Medical Physicist and Director for Safety, Radiation Physics [email protected] Patient Safety in the Treatment Process

Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

  • Upload
    dokhanh

  • View
    217

  • Download
    2

Embed Size (px)

Citation preview

Page 1: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

Applying TG-100 Methodology to SRS / SBRT

Jennifer Lynn Johnson, MS, MBASenior Medical Physicist and Director for Safety, Radiation [email protected]

Patient Safety in the Treatment Process

Page 2: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

AAPM Working Group on Prevention of Errors, Chair

Special thanks to:• Team members of the Division at Radiation Oncology• Julian R Perks, et. al.• Laura Masini, et. al.• Kelly Cooper Younge, et. al.• F Yang, et. al.• Ryan P. Manger, et. al.

Disclosures2Patient Safety in the Treatment Process

Page 3: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Clearly, we want to avoid patient harm.

We typically measure and respond to specific incidents of harm.

Can we do better?

3Patient Safety in the Treatment Process

Page 4: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Contents

1 RISK

2 SRS / SBRT QA PROGRAM

3 SRS / SBRT PROCESS

4 FAILURE MODES AND EFFECTS ANALYSIS

5 FAULT TREE ANALYSIS

6 SOPS FOR MAJOR STEPS

7 SAFETY CHECKLIST

8 PROGRAM MONITORING

Patient Safety in the Treatment Process 4

Page 5: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Risk

5Patient Safety in the Treatment Process

Page 6: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Risk is the likelihood a hazard causes harm to a patient.

What can go wrong?

How likely is it to go wrong?

What are the consequences if it goes wrong?

Defining Risk6Patient Safety in the Treatment Process

Page 7: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

RT is adopting incident learning system (ILS)

• Reactive: identify after the fact, control only for the future

• Difficult to monitor low occurrence incidents

High risk industries identify, control and monitor hazards

Allows active management of the environment

• Manage the hazards that give rise to risk

• Create resilience for unexpected risks

Risk Management7Patient Safety in the Treatment Process

Page 8: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Prospectively analyze hazards in a process.

For the RT treatment process, AAPM TG-100 uses:

• Process Mapping

• Failure Modes and Effects Analysis

• Fault Tree Analysis

Structured ways to prioritize risk and determine where to focus resources

Risk Assessment8Patient Safety in the Treatment Process

Page 9: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

SRS / SBRT is typically a complete course of radiation therapy (RT) delivered in 1 to 5 sessions (fractions).

SRS / SBRT requires greater precision and accuracy than conventionally fractionated RT => follow strict protocols for quality assurance (QA).

9Patient Safety in the Treatment Process

Page 10: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

ACR–ASTRO Practice Parameter for the Performance of Stereotactic Body Radiation Therapy. Practice guidelines and technical standards. Reston, VA: American College of Radiology; 2014: 1-11.

ACR–ASTRO Practice Parameter for the Performance of Stereotactic Radiosurgery. Practice guidelines and technical standards. Reston, VA: American College of Radiology; 2014: 1-11.

Benedict SH, Yenice KM, Followill D, et al. Stereotactic body radiation therapy: the report of AAPM Task Group 101. Med Phys. 2010;37(8):4078-4101.

Keall PJ, Mageras GS, Balter JM, et al. The management of respiratory motion in radiation oncology report of AAPM Task Group 76. Med Phys. 2006;33(10):3874-3900.

Klein EE, Hanley J, Bayouth J, et al. Task Group 142 report: quality assurance of medical accelerators. Med Phys. 2009;36(9):4197-4212.

Solberg TD, Balter JM, Benedict SH, Fraass BA, Kavanagh B, Miyamoto C, Pawlicki T, Potters L, Yamada Y. Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy. Prac. Rad. Onc. 2012; Mar 31;2(1):2-9.

Published Guidance for Comprehensive QA10Patient Safety in the Treatment Process

Page 11: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

“Central goal of patient safety is to avoid potential harm rather than compliance with systems and processes.”

11Patient Safety in the Treatment Process

Vincent C, Burnett S, Carthey J. The measurement and monitoring of safety. London: The Health Foundation. 2013 May 24;2013.

Page 12: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

SRS / SBRT Process

12Patient Safety in the Treatment Process

Page 13: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Visual illustration of the steps in a process

What is accomplished

How steps are related

Process steps may be subdivided into sub-processes, and so on.

Process Mapping13Patient Safety in the Treatment Process

Page 14: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Imaging

Treatment Planning

Dose Delivery

Generic SRS / SBRT ProcedurePatient Safety in the Treatment Process 14

Adapted from Ford, E. C., et al. "Consensus recommendations for incident learning database structures in radiation oncology." Medical physics 39.12 (2012): 7272-7290.

Page 15: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Delivering modern external beam radiation therapy is not so simple.

15Patient Safety in the Treatment Process

Page 16: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson 16Patient Safety in the Treatment Process

MDACC Radiation Oncology Process - EBRT

Adapted from Ford, E. C., et al. "Consensus recommendations for incident learning database structures in radiation oncology." Medical physics 39.12 (2012): 7272-7290.

Page 17: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Failure Modes and Effects Analysis

Fault Tree Analysis

17Patient Safety in the Treatment Process

Page 18: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Vocabulary:

• Failure mode: how a part or process can fail

• Cause: a deficiency that results in a failure mode; source of variation

• Effect: impact on a person if the failure mode is not prevented or corrected

A multidisciplinary team (experts) generate actual and potential risks (without QC)

Especially useful for high-risk processes

Structured approach that links failure modes to an effect

Failure Modes and Effects Analysis (FMEA)18Patient Safety in the Treatment Process

Page 19: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Steps:

• Identify ways a sub-process (or product) can fail, both known & potential

• Determine each failure mode’s causes & effects • Assign a number to most severe (S)

effect

• Determine likelihood each failure mode’s occurrence (O) & detection (D)

Failure Modes and Effects Analysis (FMEA)19Patient Safety in the Treatment Process

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics. 2016 Jul 1;43(7):4209-62

• Calculate risk priority number (RPN) = O x S x D

Page 20: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Rank the RPN values (highest to lowest)

Pick the 3 failure modes with the highest RPN values and highest S values

• RPN ≥ 100

• S ≥ 7

Propose process changes that would decrease the probability of occurrence, O

Propose QC that would decrease the probability of un-detectability, D

Failure Modes and Effects Analysis (FMEA)20Patient Safety in the Treatment Process

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics. 2016 Jul 1;43(7):4209-62

Page 21: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEAMDACC Exercise (2013)

21Patient Safety in the Treatment Process

Asked a multidisciplinary team to complete a survey

• For each of the sub-process steps

• Did not ask specific causesEstimating Failure Mode ScoresIn columns 2-4 of Table 1, use Table A (provided separately) to fill in your best estimate the following scores:O = Occurrence. The likelihood the failure would occur. (1-10)D = Detectability. The likelihood the failure would go undetected. (1-10)S = Severity. The severity of the consequences of the failure. (1-10)Again, imagine the worst case scenario. Consider each failure independently

• Team reviewed results together and agreed in general the RPN rankings

• Purpose for ILS action scale

Page 22: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEATreatment Planning – O, D, S

22Patient Safety in the Treatment Process

Page 23: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEAMDACC Exercise (2013) Calculating RPN

23Patient Safety in the Treatment Process

Page 24: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEAMDACC Exercise (2013) Ranking RPN

24Patient Safety in the Treatment Process

Page 25: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEAMDACC Exercise (2013) RPN vs. S

25Patient Safety in the Treatment Process

Divisional RPN Physics RPN

Page 26: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEAMDACC Exercise (2013) RPN ≥ 100

26Patient Safety in the Treatment Process

Page 27: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Completing FMEAMDACC Exercise (2013) S ≥ 7

27Patient Safety in the Treatment Process

Page 28: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Propose process changes to decrease likelihood of occurrence (O).

Propose quality control to decrease likelihood of un-detectability (D).

28Patient Safety in the Treatment Process

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics. 2016 Jul 1;43(7):4209-62

Page 29: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Evaluate the propagation of failures

• Gives visual representation of propagation of a failure in the process

• Helps identify intervention strategies to mitigate the FMEA identified risks

Fault Tree Analysis (FTA)29Patient Safety in the Treatment Process

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics. 2016 Jul 1;43(7):4209-62

Page 30: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Fault Tree Analysis (FTA)30Patient Safety in the Treatment Process

Steps

• Define the undesired event

• Understand the system

• Construct the fault tree

• Evaluate the fault tree

• Control the identified hazards

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics. 2016 Jul 1;43(7):4209-62

Page 31: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Fault Tree Analysis (FTA)31Patient Safety in the Treatment Process

Events in a fault tree are associated with statistical probabilities

• AND gate probability of output:• P(A and B) = P(A∩B) = P(A) P(B)

• OR gate probability of output:• P(A or B) = P(AUB) = P(A) + P(B) -

P(A∩B)

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Ibbott GS, Mundt AJ, Mutic S, Palta JR, Rath F, Thomadsen BR, Williamson JF. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Medical Physics. 2016 Jul 1;43(7):4209-62

Page 32: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Utilization of Process Maps, FMEA, and FTA enable development of your Quality Management program.

32Patient Safety in the Treatment Process

Page 33: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Comprehensive QA ProgramMDACC Exercise (2013) – Improvements in Progress

36Patient Safety in the Treatment Process

Immobilization and Simulation Devices

Treatment Planning System

Treatment Delivery Unit

Ancillary Systems for Imaging and Motion Management

Patient-specific Treatment Delivery Parameter Validation

Other – RO Treatment Planning

Other – Treatment Delivery

QMP, RO present

Committee review required prior release

QMP peer review QA

Improved engineering notifications

Improved SRS / SBRT treatment checklist

RTT time out process & checklist

Dosimetry checklist

RO Peer review

Page 34: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Experience39Patient Safety in the Treatment Process

Perks, J. R., Stanic, S., Stern, R. L., Henk, B., Nelson, M. S., Harse, R. D., ... & Chen, A. M. (2012). Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. International Journal of Radiation Oncology* Biology* Physics, 83(4), 1324-1329.

Page 35: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

CBCT isocenter misalignment -> vigilent IGRT QA

Automatic setup failure -> frame agreement within 2 mm CBCT

Improper laser marking or transcription error for couch movements -> instituted dry run to test need to translate patient away from iso

Patient movements during treatment -> considering infrared surface tracking

Instituted checklists

Reviewed staffing levels

Experience40Patient Safety in the Treatment Process

Perks, J. R., Stanic, S., Stern, R. L., Henk, B., Nelson, M. S., Harse, R. D., ... & Chen, A. M. (2012). Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. International Journal of Radiation Oncology* Biology* Physics, 83(4), 1324-1329.

Page 36: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Experience41Patient Safety in the Treatment Process

Masini, L., Donis, L., Loi, G., Mones, E., Molina, E., Bolchini, C., & Krengli, M. (2014). Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator. Practical radiation oncology, 4(6), 392-397.

Page 37: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Wrong collimator selection -> instituted bar code reader

Isocenter localization -> utilize infrared surface tracking for independent localization system verification

Target and OAR contours -> contour peer review

RO consults similar patients -> cross-check clinical documentation

Training, roles & responsibilities

Scheduling of treatments

Experience42Patient Safety in the Treatment Process

Masini, L., Donis, L., Loi, G., Mones, E., Molina, E., Bolchini, C., & Krengli, M. (2014). Application of failure mode and effects analysis to intracranial stereotactic radiation surgery by linear accelerator. Practical radiation oncology, 4(6), 392-397.

Page 38: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Changes perceptions of risk

Experience43Patient Safety in the Treatment Process

Younge, K. C., Wang, Y., Thompson, J., Giovinazzo, J., Finlay, M., & Sankreacha, R. (2015). Practical implementation of failure mode and effects analysis for safety and efficiency in stereotactic radiosurgery. International Journal of Radiation Oncology* Biology* Physics, 91(5), 1003-1008.

Page 39: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Mask fitting -> monitor pre-treatment and post-treatment imaging

Patient orientation on MRI -> additional staff checks

Contours -> additional auto comparison of approved versus final plan

Contours -> mandatory peer review prior to treatment planning

Experience44Patient Safety in the Treatment Process

Younge, K. C., Wang, Y., Thompson, J., Giovinazzo, J., Finlay, M., & Sankreacha, R. (2015). Practical implementation of failure mode and effects analysis for safety and efficiency in stereotactic radiosurgery. International Journal of Radiation Oncology* Biology* Physics, 91(5), 1003-1008.

Page 40: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Criterion-based FMEA compared with incidents reported in ILS

-> 61% (20/33) identified by FMEA

->39% (13/33) not identified by FMEA ->Significantly lower RPNs

Experience45Patient Safety in the Treatment Process

Yang, F., Cao, N., Young, L., Howard, J., Logan, W., Arbuckle, T., ... & Ford, E. (2015). Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy. Medical physics, 42(6), 2777-2785.

Page 41: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

16 / 91 steps surface imaging

25 / 167 had RPN >100-> 1 related to surface imaging

Use systematic approach to FMEA(e.g., HAZOP or SHERPA)

Experience46Patient Safety in the Treatment Process

Manger, R. P., Paxton, A. B., Pawlicki, T., & Kim, G. Y. (2015). Failure mode and effects analysis and fault tree analysis of surface image guided cranial radiosurgery. Medical physics, 42(5), 2449-2461.

Page 42: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Experience47Patient Safety in the Treatment Process

Manger, R. P., Paxton, A. B., Pawlicki, T., & Kim, G. Y. (2015). Failure mode and effects analysis and fault tree analysis of surface image guided cranial radiosurgery. Medical physics, 42(5), 2449-2461.

Page 43: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Experience suggests Standardized Operating Procedures (SOPs) for major steps are critical to patient safety.

48Patient Safety in the Treatment Process

Page 44: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Safety ChecklistMedical Physics Practice Guideline 4.a

49Patient Safety in the Treatment Process

Role of checklists

Organizational influences on checklists: safety culture

Teamwork is essential

Development & Implementation

Revision

Maintenance

de los Santos LE, Evans S, Ford EC, Gaiser JE, Hayden SE, Huffman KE, Johnson JL, Mechalakos JG, Stern RL, Terezakis S, Thomadsen BR. Medical Physics Practice Guideline 4. a: Development, implementation, use and maintenance of safety checklists. Journal of Applied Clinical Medical Physics. 2015 May 8;16(3).

Page 45: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Use of checklists

Design recommendations

• Content

• Workflow, layout & format

• Physical characteristics (e.g., font, text color, shading)

Safety ChecklistMedical Physics Practice Guideline 4.a

50Patient Safety in the Treatment Process

de los Santos LE, Evans S, Ford EC, Gaiser JE, Hayden SE, Huffman KE, Johnson JL, Mechalakos JG, Stern RL, Terezakis S, Thomadsen BR. Medical Physics Practice Guideline 4. a: Development, implementation, use and maintenance of safety checklists. Journal of Applied Clinical Medical Physics. 2015 May 8;16(3).

Page 46: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Safety Checklist Samples51Patient Safety in the Treatment Process

Solberg TD, Balter JM, Benedict SH, Fraass BA, Kavanagh B, Miyamoto C, Pawlicki T, Potters L, Yamada Y. Quality and safety considerations in stereotactic radiosurgery and stereotactic body radiation therapy. Practical Radiation Oncology. 2012; Mar 31;2(1):2-9.

Page 47: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Program Monitoring Patient Safety

Past harm

Reliability

Sensitivity to operations

Anticipation and preparedness

Integration and learning

Vincent, C., Burnett, S., & Carthey, J. (2013). The measurement and monitoring of safety. The Health Foundation

Patient Safety in the Treatment Process 53

Page 48: Patient Safety in the Treatment Process - SEAAPM Patient Safety.pdf · “Central goal of patient safety is to avoid potential harm rather than compliance with ... -> instituted dry

MD Anderson

Program Monitoring Patient Safety54Patient Safety in the Treatment Process

Past Harm

• SafetyLink ILS

• Outcomes

Reliability

• Improved standardized protocols and guidelines

Sensitivity to Operations

• Daily Coms

• Team operation huddles

Anticipation and Preparedness

• Checklists

• Safety culture

• Staffing indicators (absence rates)

Integration and Learning

• Walk-rounds

• Patient surveys

• Chart audits, dashboards

• ILS and RCAVincent, C., Burnett, S., & Carthey, J. (2013). The measurement and monitoring of safety. The Health Foundation


กก - safety-stou.com safety.pdfกก “ ก ˝ ” ก ˚ ˙˜ ˙ “Safety Man ”!ˆ˙ “Safety Man ” ก ˆ " “ ก ˝ ” “Staff Function ” ˚ ˙˜ ˙ “Line Function

กก - safety-stou.com safety.pdfกก “ ก ˝ ” ก ˚ ˙˜ ˙ “Safety Man ”!ˆ˙ “Safety Man ” ก ˆ " “ ก ˝ ” “Staff Function ” ˚ ˙˜ ˙ “Line Function

Documents
patien safety.pdf

patien safety.pdf

Documents
Food Safety.pdf

Food Safety.pdf

Documents
Laboratory Safety.pdf

Laboratory Safety.pdf

Documents
Boiler Safety.pdf

Boiler Safety.pdf

Documents
92058_electrical safety.pdf

92058_electrical safety.pdf

Documents
Grinding Wheel Safety Grinding Wheel Safety.pdf

Grinding Wheel Safety Grinding Wheel Safety.pdf

Documents
GAS SAFETY.pdf

GAS SAFETY.pdf

Documents
Patient Safety Movement Foundation Presents · APSS #17 –Patient Safety Curriculum Patient Safety Curriculum for All Health Professionals May 8, 2019 Patient Safety Movement Foundation

Patient Safety Movement Foundation Presents · APSS #17 –Patient Safety Curriculum Patient Safety Curriculum for All Health Professionals May 8, 2019 Patient Safety Movement Foundation

Documents
Machine Safety - Webs safety hazard/7_Machine Safety.pdf · Machine Safety Safeguarding any machine part that ... The interlocking method may be mechanical, electrical, pneumatic,

Machine Safety - Webs safety hazard/7_Machine Safety.pdf · Machine Safety Safeguarding any machine part that ... The interlocking method may be mechanical, electrical, pneumatic,

Documents
Recent Developments in Patient Safety and Scope of Patient Safety Special Interest Group Recent Developments in Patient Safety and Scope of Patient Safety

Recent Developments in Patient Safety and Scope of Patient Safety Special Interest Group Recent Developments in Patient Safety and Scope of Patient Safety

Documents
The Human-Computer User Interface and Patient Safety ...med-fom-ehealth-office.sites.olt.ubc.ca/...Human-Computer...Safety.pdf · The Human-Computer User Interface and Patient Safety:

The Human-Computer User Interface and Patient Safety ...med-fom-ehealth-office.sites.olt.ubc.ca/...Human-Computer...Safety.pdf · The Human-Computer User Interface and Patient Safety:

Documents
Safety Topic 1_Introduction to Safety.pdf

Safety Topic 1_Introduction to Safety.pdf

Documents
Driver Safety Training - EHS DB.com Safety.pdf · Driver Safety Training Facilities Management’s Environmental Health & Safety Division Presents…

Driver Safety Training - EHS DB.com Safety.pdf · Driver Safety Training Facilities Management’s Environmental Health & Safety Division Presents…

Documents
Patient Safety Evaluation System and Patient Safety Organization Fundamentals

Patient Safety Evaluation System and Patient Safety Organization Fundamentals

Documents
Electricitcal Safety.PDF

Electricitcal Safety.PDF

Documents
ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR … · ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR ... ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR . 2 PATIENT ... status

ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR … · ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR ... ELECTRICAL SAFETY ANALYZER WITH PATIENT SIMULATOR . 2 PATIENT ... status

Documents
2P SAFETY: PATIENT AND PERSONNEL SAFETYbetonghospital.net/HA FORUM 2017/patient and personal safety.pdf · Patient Safety. Goals Personnel. Safety Goals S. Safe Surgery. S Social

2P SAFETY: PATIENT AND PERSONNEL SAFETYbetonghospital.net/HA FORUM 2017/patient and personal safety.pdf · Patient Safety. Goals Personnel. Safety Goals S. Safe Surgery. S Social

Documents
Radiation Safety - BGUin.bgu.ac.il/logistics/DocLib/Pages/radiation/Radiation-Safety.pdf · Radiation Safety Radiation Safety ... isotopes occurring naturally in our own bodies

Radiation Safety - BGUin.bgu.ac.il/logistics/DocLib/Pages/radiation/Radiation-Safety.pdf · Radiation Safety Radiation Safety ... isotopes occurring naturally in our own bodies

Documents
Patient safety.pdf

Patient safety.pdf

Documents
PATIENT SAFETY Protecting Patient’s Right Protecting Patient’s Right General Patient Safety Measures General Patient Safety Measures Admission of the Patient

PATIENT SAFETY Protecting Patient’s Right Protecting Patient’s Right General Patient Safety Measures General Patient Safety Measures Admission of the Patient

Documents
railway safety.pdf

railway safety.pdf

Documents
Phoenix Contact Functional Safety - Steven Engineeringstevenengineering.com/...CONTROL_FUNCTIONAL-SAFETY.pdf · Services for functional safety 114 ... Safety devices Safety relays

Phoenix Contact Functional Safety - Steven Engineeringstevenengineering.com/...CONTROL_FUNCTIONAL-SAFETY.pdf · Services for functional safety 114 ... Safety devices Safety relays

Documents
Quality Safety.pdf

Quality Safety.pdf

Documents
Enhancing Patient Safety and Outcomes: The Safe Patient Handling … Patient Safety... · Enhancing Patient Safety and Outcomes: The Safe Patient Handling Connection Presented by

Enhancing Patient Safety and Outcomes: The Safe Patient Handling … Patient Safety... · Enhancing Patient Safety and Outcomes: The Safe Patient Handling Connection Presented by

Documents
Severe Weather Safety - Electrical Safety Foundation ...files.esfi.org/file/ESFi-Hurricane-Safety.pdf · Severe Weather Safety “Resources to help weather the storm”“Resources

Severe Weather Safety - Electrical Safety Foundation ...files.esfi.org/file/ESFi-Hurricane-Safety.pdf · Severe Weather Safety “Resources to help weather the storm”“Resources

Documents
PENNSYLVANIA PATIENT SAFETY ADVISORYpatientsafety.pa.gov/ADVISORIES/Documents/200812_home.pdf · Pennsylvania Patient Safety Advisory About the Pennsylvania Patient Safety Advisory

PENNSYLVANIA PATIENT SAFETY ADVISORYpatientsafety.pa.gov/ADVISORIES/Documents/200812_home.pdf · Pennsylvania Patient Safety Advisory About the Pennsylvania Patient Safety Advisory

Documents
Occupational Health Program Safety Training Series NITROGEN SAFETY.pdf · Occupational Health Program Safety Training Series ... Pressure Gauge - Displays internal ... Occupational

Occupational Health Program Safety Training Series NITROGEN SAFETY.pdf · Occupational Health Program Safety Training Series ... Pressure Gauge - Displays internal ... Occupational

Documents
Science Lab Safety - Tualatin Valley Academy Safety.pdf · Science Lab Safety • Fire Safety • Eye Protection • Chemical Safety • Personal Safety Precautions • Laboratory

Science Lab Safety - Tualatin Valley Academy Safety.pdf · Science Lab Safety • Fire Safety • Eye Protection • Chemical Safety • Personal Safety Precautions • Laboratory

Documents
QUALITY AND PATIENT SAFETY - jacksonhealth.org and Patient Safety.pdf · tour and questions they ask will be a big part of their inspection of our hospital. Chances are, you ... NATIONAL

QUALITY AND PATIENT SAFETY - jacksonhealth.org and Patient Safety.pdf · tour and questions they ask will be a big part of their inspection of our hospital. Chances are, you ... NATIONAL

Documents