Utilising barcode scanning to reduce the number of incidents of forgotten bolus

Abstract

Keywords: quality improvement; barcode; bolus; radiotherapy errors; safety Introduction: Since departmental change from paper to electronic patient positioning instructions, there has been a sharp increase in instances whereby bolus has been incorrectly omitted for any partial or whole treatment. These events are classified as minor radiation incidents as per the Towards Safer Radiotherapy guidelines(1). Data on these incidents is reported through Datix. Available data shows a total of 42 errors. The records extend to December 2007, with the first recorded incident in April 2009. Between December 2007 and October 2016 there were 18 incidents. Between November 2016 and the inception of this project in May 2018 there were 18 incidents. This quality improvement project seeks to utilise treatment inhibits and barcode scanning to reduce these incidents to zero. Method and Materials: A paperless workflow, utilising a custom report within MOSAIQ® (Elekta AB, Sweden), was designed for the generation of treatment field specific barcodes. These were stored individually in the patient chart and displayed in the specific field. After initial testing of a single barcode scanner, they were installed across the entire fleet of 12 linear accelerators. After in-depth end-to-end testing the process was deemed suitable for implementation and a “go live” date decided upon. A number of volunteers aided with generating barcodes for all current patients. Protocols were uploaded to the local quality management system and training delivered to staff. Results: Since inception of the project a further six errors were reported. The process went live on the 6th June 2019 for all patients with bolus. Error reports have been robustly checked since implementation. No incidents have since been reported. Conclusion and Discussion: Since implementation on the 6th June 2019 there have been no reported instances of bolus being incorrectly omitted for any patient treatments. The utilisation of the barcode scanners appears to have reduced the number of associated incidents. Results will be updated further at time of presentation. Numerical References (1) The Royal College of Radiologists, Society and College of Radiographers, Institute of Physics and Engineering in Medicine, National Patient Safety Agency, British Institute of Radiology. Towards Safer Radiotherapy. RCR; 2008.