The Application of Human Factor and System Engineering in Understanding Hardware and Software Errors at the Odette Cancer Centre

Abstract

Purpose/Aim: An urban cancer centre treats approximately 10000 courses of radiation therapy each year. 600 of these courses can be considered single fraction treatments, often administered for palliation. Although a small subset of a centre’s workload, these treatments can present a number of technical, clinical and social factors which may complicate the care of this patient population. Studies have indicated an association between this complexity and increased palliative radiation therapy error rates. The systems approach to improving quality and safety involves identifying this complex interplay of factors and mitigating the effects of the factors using strategic improvements. Method/Process: A clinically significant incident in which a patient receiving large dose single fraction treatments of palliative radiation was identified, incident analysis performed and a number of action items identified. This quality initiative focused on the implementation of a pretreatment checklist for high risk treatments. This checklist highlighted a number of risk factors often associated with single fraction patients including; laterality; previous tattoos; shifts; premedication; imaging considerations and other potential difficulties. A staff survey was performed to assess, usability, compliance, and confidence with the tool. Results/Benefits/Challenges: Of the staff surveyed (n1⁄427). 90.0% had used the checklist in their practice, identifying a usage rate of 78.4% of single fraction patients. The largest barriers to use identified included inadequate time and patients not viewed as enough of a risk. Staff identified that previous tattoos and shifts were the largest factors influencing their confidence that their patients were properly prepared for treatment; whereas identifying an imaging plan was noted as having the least influencing on their confidence. Conclusion/Impact/Outcomes: Incident analysis has identified the need for consideration of complexity and workload factors in designing process improvements for the delivery of safe care in palliative radiation therapy. The applied intervention of the high risk pre-treatment checklist resulted in a global confidence score of 71.1% for all items surveyed. Process improvements have the potential to improve the quality and safety of palliative radiation treatments and these improvements can arguably be applied to all aspects of radiation delivery.