MO‐D‐230A‐05: Medical Error Detection and Reduction Plan in Community Cancer Center

Abstract

Purpose: An error reporting program, called the Medical Error Reduction Plan, was developed in our department. The program includes errors made during the patient treatment preparation process and delivery. The purpose of this study is to understand the types of errors, error frequency and trending, correlation between errors, error severity and impact on treatment quality, and to derive an error reduction strategy based on non‐punitive principles. Method and Materials: The plan supplements all required QA processes and procedures in Radiation Oncology. After patient treatment plan approval, the Therapists Check Station performs a final comprehensive check that includes: plan revision, patient setup, data entered to R&V system, approvals and scheduling. Problems are recorded in a Discrepancy Log Book that includes also errors in simulation and incomplete directives/forms. All these data are presented, discussed and analyzed at the monthly departmental meetings. We have two full years of data combined into the following categories: simulation, planning, approvals, logistics, documentation and treatment. Errors in patient treatments have been recorded in our Department as Unintended Deviations. They are presented on graphs together with data from our error reduction plan. Results: During the past two years, 350 errors were reported. Most of them (60%) were clerical, simulation and treatment planning errors accounted for 11% and 17%, respectively. At the end of the analyzed period, there was more than 50% overall reduction of treatment errors. The introduced error reporting program increased personnel alertness to treatment process details. Conclusions: The idea of a “user friendly” error detection and reduction program has proven excellent. Despite of multiple QA procedures and the R&V system, the possibility to make errors still exists. It is imperative to detect them before treatment. This process should be ongoing in view of increasing novelty and complexity of treatments.