Reducing Errors in Radiation Treatment Through the Implementation of Electronic Safety Checklists

Abstract

To implement electronic safety checklists to reduce treatment errors reaching patients. IRB approval was obtained and an electronic safety checklist software program was written to interface with electronic patient information treatment software. The checklist items were developed by reviewing errors previously reported in our error reporting system. A separate safety checklist was developed for each step in the workflow from CT simulation to radiation start: CT simulation, physician contouring, dosimetrist planning, physics and radiation therapist check. Each checklist was completed before the plan could progress. The number of reported errors was examined starting from before the development of our department’s error reporting system until after the implementation of the safety checklist program. The severity of errors was graded according to the Radiation Error Scoring System (J Am Coll Radiol 2009;6:45-50). In this system, grade 1 and 2 errors are classified as “near misses,” and grade 3 and 4 errors as those reaching the patient. To assess safety culture, the United States Department of Health Hospital Survey on Patient Safety Culture was sent to staff before and after the implementation of the checklist program. Reported errors increased over time, including after the implementation of the safety checklists. Before implementing the error reporting system an average of 2.2 errors were reported per month (101 errors from 1/2009 - 9/2012). Of these errors, 73% were grade 1, 14% grade 2, 9% grade 3 and 4% grade 4. After implementing the error reporting system in 10/2012 but before implementing the safety checklist program, an average 11.4 errors were reported per month (161 errors from 10/2012 - 11/2013). Of these errors, 157 were grade 1 (97%), 4 were grade 2 (3%) and none were grade 3 or 4. After implementing the checklist program in 12/2013, an average 16.5 errors were reported per month (33 errors from 12/2013 - 1/2014, all grade 1). The only domain of the safety culture survey that was significantly different before and after the implementation of the checklist program was “Staffing”, with a positive response rate of 64% before and 75% during checklist implementation (p = 0.04). All the other domains of the survey, including “Overall Perceptions of Patient Safety” were not different (p > 0.05). Implementing our electronic safety checklist was associated with an increase in reported errors. There seemed to be a trend toward reducing the severity of errors (more reported “near misses,” less errors reaching the patient), although more time is needed to determine if the safety checklists actually reduce the number of errors reaching patients. The safety culture of the department, as measured by a validated survey, did not suffer from implementation of a new process and even improved in one domain.