Near miss or safety incident in patients treated with radiotherapy: What are the contributing factors?

Abstract

36 Background: To identify 1) factors that are associated with a near miss or safety incident (NMSI) in patients undergoing radiation therapy; 2) the most common root causes of NMSIs and their relationship with incident severity. Methods: We retrospectively studied NMSIs filed between October 2014 and April 2016. We extracted patient-, treatment-, and disease-specific data from patients with a NMSI (n=200; incident group) and a similar group of control patients (n=200) matched in time, without a NMSI. A root cause was determined for each incident. A univariate analysis was performed to determine which patient-, disease-, and treatment-specific factors were different between the incident and control groups. Next, multivariate logistic regression was used to determine the significant factors contributing to NMSIs. Multivariate logistic regression was used to determine the most common root causes of NMSIs and their relationship with incident severity. A p value of 0.05 was used to test the statistical significance. Results: NMSIs were associated with the following factors: i) head and neck treated sites versus other disease sites (OR 5.2, p=0.01), ii) image-guided intensity modulated radiotherapy (IGIMRT) versus other treatment modalities (OR 3, p=0.009); tumors staged as T2 more frequently had incidents versus other T stages (OR 3.3, p=0.004), and iv) daily imaging versus no imaging or weekly imaging (OR 7, p<0.001). Documentation and scheduling errors were the most common root causes (29%). Communication errors were more likely to affect patients (p<0.0001) and technical treatment delivery errors were most associated with a higher severity score (p=0.005). Conclusions: Several treatment- and disease-specific factors were found to be associated with a NMSI. These factors are similar to what has been previously reported by others. Overall, our results suggest that complexity (e.g., head and neck, IGIMRT, T2, and daily imaging) might be a contributing factor for a NMSI. This promotes an idea of developing a more dedicated and robust QA system for complex cases. Our study highlights the importance of a strong reporting system to support a safety culture and promote continuous learning and improvement efforts.