Use of the Patient Safety Alert (PSA) System to Improve the Treatment Verification Process

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Verification of the isocenter and fields generated from the treatment plan by the radiation oncologist (RO) before delivery of radiation treatment is critical. Rarely, an error such as misidentification of the isocenter could occur resulting in underdosing the target and/or unnecessarily irradiating normal tissue. We implemented the PSA system to perform a root cause analysis and mistake-proof this process. The PSA system is used to facilitate timely identification, reporting, and follow-up on variations in the quality of care or operations for all departments at our institution. Once an occurrence is reported, the PSA specialist, department leadership, and all team members involved meet to perform a root cause analysis. We identified an error in the treatment verification process that led to placement of the isocenter one vertebral body inferior to what was designated by the treatment plan for a particular patient and generated a PSA. Factors identified as contributing to the error included miscommunication, poor image quality, lack of key anatomical structures to reference the level of vertebral bodies, and delay in timely RO peer review of treatment fields (successive check). A corrective action plan was created which involved modifications to the standard work for the treatment verification process. Modifications included using standard terminology among all staff and providers to prevent miscommunication, inclusion of the iliac crests in the DRRs and the portal images to provide an anatomical reference point when applicable, and a successive check by another RO before start of treatment for any patient not undergoing daily image-guided therapy. Once the isocenter and the digital electronic portal images of treatment fields were approved by the first RO, they were copied and reviewed the next day by a second RO at morning rounds prior to the first treatment. There was no additional radiation dose or prolongation of time on the treatment table/discomfort to the patients. In the first 3 months of implementation of the new process, there were 85 treatment verifications requiring successive checks. One patient did not have a successive check done and one had it done after the second treatment. Once, the second RO review did not agree with the first RO review due to minor differences in patient positioning compared to DRR. No treatment errors have occurred since implementation of the new standard work. A survey of the staff and ROs revealed that the improvements in the standard work did not cause any disruptions or inefficiencies in the work flow. Using the PSA system, root cause analysis and development of a corrective action plan created an improved standard process for treatment verification with minimal cost, impact to the patient, and disruptions to the work flow of the department.