Abstract
Purpose: The Joint Commission has encouraged the healthcare industry to become “High Reliability Organizations” by “Chasing Zero Harm” in patient care. In radiation oncology, the time point of quality checks determines whether errors are prevented or only mitigated. Thus, to “chase zero” in radiation oncology, peer review has to be implemented prior to treatment initiation. A multidisciplinary group consensus peer review (GCPR) model is used pre-treatment at our institution and has been successful in our efforts to “chase zero harm” in patient care.Methods: With the GCPR model, policy-defined complex cases go through a treatment planning conference, which includes physicians, residents, physicists, and dosimetrists. Three major plan aspects are reviewed: target volumes, target and normal tissue dose coverage, and dose distributions. During the review, any team member can ask questions and afterwards a group consensus is taken regarding plan approval.Results: The GCPR model has been implemented through a commitment to peer review and creative conference scheduling. Automated analysis software is used to depict color-coded results for department approved target coverage and dose constraints. About 8% of plans required re-planning while about 23% required minor changes. The mean time for review of each plan was 8 min.Conclusions: Catching errors prior to treatment is the only way to “chase zero” in radiation oncology. Various types of errors may exist in treatment plans and our GCPR model succeeds in preventing many errors of all shapes and sizes in target definition, dose prescriptions, and treatment plans from ever reaching the patients.
Highlights
AND INTRODUCTIONSince the release of the seminal report from the Institute of Medicine (IOM) titled, “To Err is Human,” in 1999, the importance of patient safety and avoiding medical errors have been recognized and endorsed by the physician community, as well as by governing bodies and accreditation agencies [1]
We must make that assumption when we identify procedures such as pre-treatment peer review that would be effective at preventing errors, but may induce more burden on staff
We argue that all radiation oncology departments need to become High Reliability Organization (HRO) to achieve the goal of zero harm to our patients
Summary
With the GCPR model, policy-defined complex cases go through a treatment planning conference, which includes physicians, residents, physicists, and dosimetrists. Three major plan aspects are reviewed: target volumes, target and normal tissue dose coverage, and dose distributions. Any team member can ask questions and afterwards a group consensus is taken regarding plan approval
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