Large Radiation Oncology Research Articles

Implementing an Electronic Data Capture System to Improve Clinical Workflow in a Large Academic Radiation Oncology Practice.

To describe the feasibility and benefits of implementing a custom radiation oncology electronic data capture (EDC) system in a large academic radiation oncology practice. A Web-based point-and-click EDC known as Brocade was internally developed and implemented systemwide in 2016. Brocade captures key data elements, such as stage, histology, and patient and treatment characteristics; links this information to radiation dose data extracted from the record and verify system; and creates clinical notes that are automatically exported to the hospital electronic health record. We report the number of unique radiation episodes captured by Brocade in its first full year of implementation and describe the notes generated, toxicities captured, compliance with staging and quality assurance, and time of day in which documentation occurred with Brocade versus our prior human transcription system. A median of 756 radiation episodes per month was captured for a total of 9,283 unique episodes captured in the first full year of implementation. The most common notes were for on-treatment visits (29,913) and simulations (13,220). Stage was captured for 92.2% of Brocade episodes (8,513 of 9,236) versus 29.7% of courses pre-Brocade (3,025 of 10,170; P < .001). Quality assurance was documented for 96.3% of completed courses (7,601 of 7,892). The most common grade ≥1 toxicities were pain (10,031), fatigue (7,490), and dermatitis (6,172). Brocade implementation was associated with a reduction in off-hours documentation and increase in the proportion of documentation created between 8:00 am and 12:00 pm. Brocade is a reliable Web-based EDC tool that improves clinical documentation without detracting from clinical workflow. Moreover, Brocade has the advantage of capturing data in a structured manner that facilitates real-time analytics and outcome reporting.

Improving Timely Completion of Radiation Therapy End of Treatment Summaries in a Large Multi-Site Radiation Oncology Department

End of Treatment Summaries (EOTs) in radiation oncology are a critical component of communication among the radiation oncologist, care team, and patient. In addition, systematic completion of EOTs is a quality metric among several accrediting bodies in Radiation Oncology. We sought to institute a program to improve the timely completion of EOTs in a large multi-site academic Radiation Oncology department. A pre-post quality improvement study was conducted within our department’s main center and a sample of regional network sites. The aim was to improve the rate of EOTs sent within 15 days of the last day of treatment, which was based on ASTRO Accreditation Program for Excellence (APEx) standards. To quantify the pre-intervention state, baseline data characterizing the time between the end of the radiotherapy course and completion of the EOT was collected over a 6 month period. Qualitative interviews were also conducted to understand perceived barriers to timely completion of EOTs. A multi-tiered intervention was instituted to address these limiting factors. The days elapsed between the end of radiation treatment and EOT completion was subsequently monitored. Differences in the rate of EOTs completed within 15 days before and after our intervention were assessed using the chi-square test. In the baseline and post intervention periods, 1408 and 2500 radiotherapy courses were completed, respectively. Baseline percentages of EOTs completed within 1-15 days, 16-30 days, >30 days, and unsent over the 6 month period was 38%, 12%, 19%, and 31%, respectively. Barriers to timely completion of EOTs included a need for more expedient notification as to when patients complete treatment, a multi-step, inconsistently implemented workflow for creating and sending EOTs, competing clinical obligations, and inadequate physician incentives. Therefore, our intervention consisted of 1) automated notifications to physicians at patient end of treatment, 2) improved pre-population of relevant patient data into the EOT using the electronic medical record, 3) a streamlined EOT workflow with re-education on the EOT completion process for physicians and administrative support, and 4) public reporting of EOT completion rates by individual physician. Following our intervention, percentages of EOTs completed within 1-15 days, 16-30 days, >30 days, and unsent were 64%, 12%, 10%, and 15%, respectively (p<0.001) over the 12 month period. The final average time to completion of the EOT decreased from 27 days pre-intervention to 10 days post-intervention. Using a multimodality approach, we improved both the expediency and total rate of EOT completion in a large multi-site radiation oncology department. Further efforts are needed to demonstrate the durability and enhance the impact of these interventions.

A Robust Structure for Quality and Safety in a Large Academic Radiation Oncology Practice

Quality and safety programs (QSP) are critical to ensure zero patient harm and are a cornerstone for high reliability organizations. The purpose of this study is to assess the strength and structure of a QSP in a large academic radiation oncology practice. Beginning in July 2016, a new electronic incident learning system (ILS) was implemented for reporting safety concerns in our large, radiation oncology practice, comprised of a primary institution plus 6 campuses including a proton center, with 889 employees, including 65 fully credentialed radiation oncologists, 7 newly on-boarded radiation oncologists, 78 medical physicists, 60 nurses, 47 medical dosimetrists, 105 radiation therapists, and 21 advanced practice providers. We also initiated an electronic system for capturing quality assurance peer review of all radiation treatment plans, including single-fraction radiosurgery, boosts, and palliative treatments. Here we review the safety reporting and quality outcomes of our large department for fiscal year 2017 (FY17 – Sept 2016-Aug 2017) using descriptive analyses. A total of 9,124 new patients were treated with a total of 171,500 external beam radiation treatments in FY17. More than 1,800 reports were submitted through the ILS during FY17. There were no level 1 (state reportable) events, three level 2 events, 132 level 3 events, and 1,667 level 4 (near miss) events. The level 2 events were further investigated, including two formal root cause analyses. The most commonly reported issues were scheduling errors caused by Radiation Oncology (10%), ineffective communication (6%), and record and verify concerns identified at time of medical physics initial plan review (5%). A total of 9,653 patient radiation treatment plans were evaluated as part of the quality assurance peer review process, of which less than 1% (n=82) had major revision recommended, 3% (n=299) had minor changes suggested and 7% (n=711) were approved with discussion. Based on analysis of the ILS reports in FY17, communication and scheduling remain challenging areas for our practice and will be the focus for improvement in FY18. The success of our quality assurance peer review process exceeds the requirements of radiation oncology accreditation bodies in the Unites States and serves as a model for other radiation oncology practices.

Impact of Intensity Modulated Radiation Therapy on Acute Toxicity in Locally Advanced Lung Cancer: Results of a Large Statewide Multi-center Cohort

Secondary analysis of RTOG 0617 has shown lower rates of pneumonitis and less decline in patient quality of life with the use of intensity modulated radiation therapy (IMRT) versus three-dimensional conformal external beam radiation therapy (3D-CRT) in locally advanced non-small cell lung cancer patients undergoing definitive radiation therapy. In a large statewide radiation oncology quality consortium, we sought to evaluate impact of IMRT vs. 3D-CRT treatment technique on acute esophagitis and pneumonitis. From 2013 to 2017, 1919 patients with non-metastatic lung cancer were enrolled in the consortium. Physician reported toxicity by CTCAE and patient reported outcomes using FACT Lung Cancer Subscale (LCS) and FACT Trials Outcome Index (TOI) were collected at 1, 3 and 6 months from the end of radiation. We compared physician and patient reported quality of life by treatment technique. Normal tissue dose volume constraints and PTV objectives were not prospectively controlled. To account for differences in prognostic factors between IMRT and 3D-CRT patients, we performed inverse probability of treatment weighting (IPTW) via a propensity score. The propensity score was estimated via a logistic regression model and included age, smoking status, comorbidities, stage, PTV volume, chemotherapy, prescription dose, total number of structures and individual structures (e.g. esophagus, heart) within 2cm of the PTV. There were 1237 non-surgical locally advanced lung cancer patients met inclusion criteria. After excluding patients with missing variables, 1062 (86%) were included in the analysis. 31% were treated with 3D-CRT and 69% were treated with IMRT. Compared with 3D-CRT patients, IMRT patients had significantly larger PTVs (mean 370 vs 474cc) and were more likely to be stage IIIB (24% vs 32%). In logistic regression models using IPTW, there were no significant differences between 3D-CRT and IMRT in rates of esophagitis (Odds Ratio =0.95; 95% CI=0.70, 1.32; p=0.76) or pneumonitis (OR = 0.91; 95% CI:0.43, 1.92; p=0.80). At 6 months after completion of RT with a compliance of 45%, 3D-CRT and IMRT resulted in similar proportions of patient experiencing a decline of at least 2 points on LCS (38% vs 45%, p=0.33) and at least 5 points on TOI (48% vs 54%, p=0.72). In these data from a statewide consortium of academic and community radiation oncology practices, despite the PTV being larger among patients treated with IMRT vs 3D-CRT, no significant difference in acute esophagitis or pneumonitis by radiation treatment technique was found. Further analysis is underway seeking to use patient variables and dose relationships to identify a subgroup of patients in which IMRT may reduce toxicity relative to 3D-CRT.

Impact of a Continuing Quality Control Review on Physics Quality Management and Radiation Safety Program in a Large Radiation Oncology Network: Multiyear Experience

Impact of a Continuing Quality Control Review on Physics Quality Management and Radiation Safety Program in a Large Radiation Oncology Network: Multiyear Experience

Developing a Culture of Safety in a Large Academic Radiation Oncology Practice Through Strategic Implementation of Anonymous and Non-anonymous Reporting Systems

Many radiation oncology practices use comprehensive Incident Learning Systems (ILS) to collect data on patient safety events. Despite the vast use of these applications throughout radiation oncology, many practices continue to struggle with the fundamental cultural challenges associated with reporting incidents and safety concerns, including fear of retaliation and intimidation. The purpose of this study is to increase reporting compliance in the practice by introducing a simplified anonymous reporting system (ARS) concurrently with an ILS. A robust ILS was developed and deployed in conjunction with a simplified ARS at a single academic institution, and data were collected from submitted reports over a 23-month period from February 2015 to December 2016. Descriptive analyses were used to evaluate reporting patterns. In addition to the reporting tools, the practice leadership routinely promoted reporting of all incidents and near misses, conveyed a zero-tolerance retaliation position and deployed an event reporting policy which defined expectations of reporting errors. A total of 2,275 reports were submitted, 608 anonymously and 1,667 non-anonymously. Over the course of the study, the five month moving average increased from 45.4 reports/month to 138.4 reports/month (mean, 98.9; range, 3 – 162). Overall, the percentage of total reports filed anonymously dropped from 53.8% (49 Anonymous, 42 Non-Anonymous, 91 Total) in Month 1-3 to 9.7% (38 Anonymous, 355 Non-Anonymous, 393 Total) in Month 21-23. It is important to note that during the study, 14 patient safety reports were submitted in the ARS with identifiable reporter characteristics (i.e. name, employee ID). These data were added to the non-anonymous ILS data set. Results suggest a significant cultural change has occurred, and fear of retaliation or intimidation has decreased. Concurrent implementation of both an ARS and a comprehensive ILS with supporting practice changes and infrastructure has decreased overall fear of retaliation and intimidation while increasing patient safety reporting compliance.

Time-Driven Activity-Based Costing (TDABC) in Radiation Oncology: A Method for Implementation

Time-Driven Activity-Based Costing (TDABC) has gained popularity in the healthcare industry, but little information exists on the benefits and strategies for implementation within Radiation Oncology. Furthermore, the data may provide insight into opportunities for operational improvements. We sought to implement TDABC in a large academic radiation oncology practice using a customized approach and minimal resources. A multidisciplinary team was created to oversee and maintain the project scope, timeline and task list. Adaptability was noted as a key to project success, so a weekly schedule was established for team huddles. The data collection plan was divided into four phases: Process mapping, validation, resource allocation, and final validation. The resulting data were combined and organized into a functional tool allowing for scenario-specific analysis using treatment plan-specific variables (e.g. fractionation, complexity, on-treatment-visit volume, adaptive planning, verification simulation, etc.). The initiative required approximately 1.5 staff to manage over a 6 month period. Overall, 9 disease-site sections were considered. Between 16 and 18 workflow maps were produced within each section, resulting in approximately 44 unique cost profiles per section. Process maps for simulation, treatment planning, physics check and treatment delivery all contained cost profiles for each relevant treatment modality for each section. Initial analyses were performed on the Head and Neck (HN) and Genitourinary (GU) sections following the final phase of data collection. A 30 fraction (Fx) IMRT head and neck plan and a 39 Fx IMRT prostate plan were analyzed. 25% and 46% of total costs were accrued in the treatment delivery phase of the head and neck and prostate plans, respectively. The higher fractionation and additional time needed for patient set-up for the prostate plan were among multiple variables contributing to the difference in cost breakdown. Treatment delivery accounted for the largest proportion of total costs in both scenarios. On-Treatment-Visits (OTV) accounted for 16% and 20% of total costs for head and neck and prostate plans, respectively whereas Initial Consult Visits accounted for 13% and 12%, respectively. 15% of total costs in the head and neck scenario were attributed to head and neck section-specific processes such as joint physical examination and a minimum of one standard verification simulation during treatment. We conclude that TDABC can be implemented and sustained with the strategy outlined in our study. The data can provide insight into process variation and opportunities for operational improvement.

A modified Edmonton Symptom Assessment Scale for symptom clusters in radiation oncology patients.

Patient‐reported outcomes regarding symptom burden may provide valuable information in addition to physician assessment. Systematic collection of patient‐reported outcomes may be an important metric to identify unmet needs and improve quality of patient care. To understand common symptoms of patients seen in radiation oncology clinic, we examined the prospectively collected modified Edmonton Symptom Assessment Scale (ESAS‐r) data to explore symptom clusters. Our clinic established use of a modified Edmonton Symptom Assessment Scale in August 2015. All outpatients presenting for radiation oncology services completed the form at each clinic visit. Symptom clusters are defined by two or more symptoms that are interrelated and occur simultaneously with a high degree of predictability. A sample of 916 de‐identified surveys was assessed statistically using principal component analysis (PCA) with varimax rotation to determine independent clustering between the symptoms queried. We found four major clusters of symptoms: Tiredness (tired, drowsiness; PC1), Loss of Appetite (nausea, lack of appetite; PC2), Low Well‐Being (overall & spiritual well‐being; PC3), and Depression (depression, anxiety; PC4). These accounted for 46%, 9.2%, 7.6%, and 7% of total variance, respectively. Internal consistency using Cronbach's alpha was 0.87, 0.7, 0.82, and 0.87, respectively. The most frequent write‐in item was itchiness, present in 24% of the 148 patients responding. Assessment of patients seen in a large radiation oncology clinic revealed several symptom clusters. {Tiredness and drowsiness} represents a major symptom cluster. Itchiness may be underrecognized.

PRADO: A Palliative Care Model for Every Radiation Oncology Practice

During the past few years, large academic radiation oncology programs have uncovered a significant gap in providing palliative care to hospitalized cancer patients. The renowned SPRO (Supportive and Palliative Radiation Oncology) service at Brigham and Women's Hospital ( 1 Tseng Y.D. Krishnan M.S. Jones J.A. et al. Supportive and palliative radiation oncology service: Impact of a dedicated service on palliative cancer care. Pract Radiat Oncol. 2014; 4: 247-253 Google Scholar ) has charted the waters since 2011. Similar programs have begun, including, but not limited to, inPROV (Inpatient Palliative Radiation Oncology Service at Vanderbilt) ( 2 Stavas M.J. Pagan J.D. Varma S. et al. Building a palliative radiation oncology program: From bedside to B.E.D. Pract Radiat Oncol. 2017; 7: 203-208 Google Scholar ) and SOPR (Supportive Oncology and Palliative Radiotherapy at the University of Pennsylvania), which have provided a tremendous benefit to patients, improvements in physician satisfaction, and increases in patient volumes. These academic programs have also incorporated closer follow-up protocols for a subset of patients with metastatic disease, who have a greater risk of requiring additional radiation treatment (RT), such as patients who have received a single fraction of palliative RT (8 Gy × 1) or patients with central nervous system involvement or oligometastatic disease.

A clinical perspective on regional nodal irradiation for breast cancer

The goal of regional treatments in breast cancer should be to eradicate any disease within lymph nodes, avoid regional recurrences, minimize the risk of distant metastases, and improve survival. In addition, regional treatments should focus on reducing potential morbidities and optimizing the long-term quality of life of breast cancer survivors. While data from recent surgical and radiation trials have helped clarify many issues regarding regional treatment, there still remains controversy as to the optimal approach for patients with “intermediate risk” disease. Two large radiation oncology studies (MA.20 and EORTC2292-10925) evaluated whether more extensive lymphatic treatment benefited patients with higher-risk lymph node-negative, or lower risk lymph node-positive disease. A meta-analysis of these two studies suggested that the addition of regional nodal irradiation (RNI) to the level III axillary, supraclavicular and upper internal mammary lymph nodes conferred an improvement in disease free survival and distant metastasis free survival as well as a 1–2% overall survival advantage. However, other studies have suggested that many patients with positive sentinel lymph nodes who are treated with breast conservation including breast irradiation may safely avoid the morbidity and costs of further axillary treatment (whether surgical or radiotherapy-based). In general, patients with 1–3 positive lymph nodes or high-risk, node negative stage II breast cancer represent a diverse population who require individualized, rather than group-based, risk assessment when considering RNI. This article will propose a strategic methodology to assess the modern day breast cancer patient's need for RNI in the setting of changing surgical, radiation, and systemic therapies.

Measuring cost in the value equation using time-driven activity-based costing (TDABC) at The University of Texas MD Anderson Cancer Center, Division of Radiation Oncology.

e18305 Background: The cost of a full cycle of radiation therapy at MD Anderson Cancer Center has not been determined using a bottom-up measurement approach. Due to the complexity and variation in clinical processes, typical costing strategies do not provide the level of detail necessary to evaluate the value equation, defined as outcomes over cost. To address this limitation, we designed and implemented a practice-wide Time-Driven Activity-Based Costing (TDABC) strategy to capture our total direct cost of care for all treatment modalities within each of 9 disease site-specific services. Methods: Process maps were created for each of the 9 disease site-specific services. Care delivery times were captured by treatment modality for each service as determined by multidisciplinary teams routinely performing each step of the process. The data were entered into a standardized tool, which calculated step costs based upon capacity cost rates for each human resource. The costing tool also calculated total direct labor costs for specific treatment plans based on modality, complexity, and fractionation. Results: The analysis took six months to complete and required the use of approximately 1,000 administrative hours, 250 physician hours, 250 clinical staff hours and 100 medical physics hours. Approximately 17 process maps were created for each of the 9 services with each process map receiving further analysis based upon radiation treatment modality. As a result of observed variation in costs between disease-site services, best practices were identified and 15 standardization opportunities were discovered. Additionally, the cost-benefit analysis between high profile modalities within each disease-site service, such as Proton Therapy and Intensity Modulated Radiation Therapy (IMRT) on the Head and Neck service, were easier to complete. Conclusions: Time-Driven Activity-Based Costing is a valid method for calculating direct costs in a large academic radiation oncology practice. Standardized clinical outcome data can be used to complete the value equation and ultimately provide insight for better clinical and administrative decision making.

Assessing the Impact of Radiation Oncology Care Plans on Workflow Management within a Large Radiation Oncology Department

Assessing the Impact of Radiation Oncology Care Plans on Workflow Management within a Large Radiation Oncology Department

Journey Toward High Reliability: A Comprehensive Safety Program to Improve Quality of Care and Safety Culture in a Large, Multisite Radiation Oncology Department.

High-reliability organizations (HROs) focus on continuous identification and improvement of safety issues. We sought to advance a large, multisite radiation oncology department toward high reliability through the implementation of a comprehensive safety culture (SC) program at the University of Pennsylvania Department of Radiation Oncology. In 2011, with guidance from safety literature and experts in HROs, we designed an SC framework to reduce radiation errors. All state-reported medical events (SRMEs) from 2009 to 2016 were retrospectively reviewed and plotted on a control chart. Changes in SC grade were assessed using the Agency for Healthcare Research and Quality Hospital Survey. Outcomes measured included the number of radiation treatment fractions and days between SRMEs, as well as SC grade. Multifaceted safety initiatives were implemented at our main academic center and across all network sites. Postintervention results demonstrate increased staff fundamental safety knowledge, enhanced peer review with an electronic system, and special cause variation of SRMEs on control chart analysis. From 2009 to 2016, the number of days and fractions between SRMEs significantly increased, from a mean of 174 to 541 days (P < .0075) and 21,678 to 113,104 fractions (P < .0028) preintervention and postintervention, respectively. Agency for Healthcare Research and Quality results demonstrate a high patient SC grade over time. Our journey toward becoming an HRO has led to the development of a robust SC through a comprehensive safety framework. Our multifaceted initiatives, focusing on culture and system changes, can be successfully implemented in a large academic radiation oncology department to yield measurable improvements in SC and outcomes.

The implementation and assessment of a quality and safety culture education program in a large radiation oncology department

In 2010, the American Society for Radiation Oncology launched a national campaign to improve patient safety in radiation therapy. One recommendation included the expansion of educational programs dedicated to quality and safety. We subsequently implemented a quality and safety culture education program (Q-SCEP) in our large radiation oncology department. The purpose of this study is to describe the design, implementation, and impact of this Q-SCEP. In 2010, we instituted a comprehensive Q-SCEP, consisting of a longitudinal series of lectures, meetings, and interactive workshops. Participation was mandatory for all department members across all network locations. Electronic surveys were administered to assess employee engagement, knowledge retention, preferred learning styles, and the program's overall impact. The Agency for Healthcare Research and Quality (AHRQ) Survey on Patient Safety Culture was administered. Analysis of variance was used for statistical analysis. Between 2010 and 2015, 100% of targeted staff participated in Q-SCEP. Thirty-three percent (132 of 400) and 30% (136 of 450) responded to surveys in 2012 and 2014, respectively. Mean scores improved from 73% to 89% (P < .001), with the largest improvement seen among therapists (+21.7%). The majority strongly agreed that safety culture education was critical to performing their jobs well. Full course compliance was achieved despite the sizable number of personnel and treatment centers. Periodic assessments demonstrated high knowledge retention, which significantly improved over time in nearly all department divisions. Additionally, our AHRQ patient safety grade remains high and continues to improve. These results will be used to further enhance ongoing internal safety initiatives and to inform future innovative efforts.

The Implementation and Assessment of a Quality and Safety Culture Education Program in a Large Radiation Oncology Department

In 2010, ASTRO launched a national plan, Target Safely, to improve patient safety and reduce the risk of medical errors in radiation therapy. One recommendation was the expansion of quality and safety education. To meet this objective, we implemented a quality and safety culture education program (Q-SCEP) to improve awareness of human errors and high-risk situations. The purpose of this study was to describe the design, implementation, and impact of a novel Q-SCEP in a large radiation oncology department. Beginning in 2010, a course entitled “Human Error Fundamentals” was instituted to educate our department on quality and safety culture (SC) fundamentals. Over 19 sessions were offered across all 7 network sites. Participation was mandatory for all, except research-only staff. In 2013/early 2014, an updated course, “Human Error Reduction and a Strong SC” was again required for the same targeted audience. Courses consisted of lectures and workshops led by our quality and safety manager and/or external safety consultant; a syllabus of relevant literature was provided. In 2012 and 2014, electronic surveys were administered using the internet-based survey system to evaluate employee engagement, SC knowledge, learning styles, and the program’s impact; ANOVA was used for statistical analysis. One hundred percent of all targeted staff participated in the courses between 2010 and 2015; 33% (132/400) and 30% (136/450) of the department responded to surveys in 2012 and 2014, respectively. There was broad representation of the clinical, radiobiology and physics divisions; overall, mean scores improved from 73% to 89% (P<.001) with the largest improvement amongst therapists (+21.7%). Both years, attending physicians scored the highest and most respondents preferred aural learning formats. Over 87% strongly agreed or agreed that ample SC educational opportunities had been provided to them, and 90% strongly agreed or agreed that SC education was critical to performing their job well. Our Q-SCEP improved staff awareness and knowledge and was of significant value to clinical practice. Full compliance with the mandatory courses was achieved despite the sizable number of participants and treatment centers within the department. Postcourse assessments demonstrated high knowledge retention that significantly improved over time in nearly all department divisions. These results will be used to further enhance ongoing internal safety initiatives and inform future efforts to expand our Q-SCEP model to other departments nationwide.Poster Viewing Abstracts 3240; Table 1Survey Results of Main DivisionsResponse Rate % (n)Mean Score (%), SDP valueYear2012201420122014Totaln=132n=13673, 1.689, 1.4<.0001Therapy29% (38)24% (33)65, 1.786, 1.4<.0001Attendings17% (22)13% (17)82, 1.293, 1.0.05Physics11% (14)16% (22)79, 0.095, 0.0<.0001Nursing10% (13)8% (11)78, 0.197, 0.1<.0001 Open table in a new tab

Examining Patient Perceptions of Quality and Safety in a Large Radiation Oncology Department

Examining Patient Perceptions of Quality and Safety in a Large Radiation Oncology Department

Physician attitudes and practices related to voluntary error and near-miss reporting.

Incident learning systems are important tools to improve patient safety in radiation oncology, but physician participation in these systems is poor. To understand reporting practices and attitudes, a survey was sent to staff members of four large academic radiation oncology centers, all of which have in-house reporting systems. Institutional review board approval was obtained to send a survey to employees including physicians, dosimetrists, nurses, physicists, and radiation therapists. The survey evaluated barriers to reporting, perceptions of errors, and reporting practices. The responses of physicians were compared with those of other professional groups. There were 274 respondents to the survey, with a response rate of 81.3%. Physicians and other staff agreed that errors and near-misses were happening in their clinics (93.8% v 88.7%, respectively) and that they have a responsibility to report (97% overall). Physicians were significantly less likely to report minor near-misses (P = .001) and minor errors (P = .024) than other groups. Physicians were significantly more concerned about getting colleagues in trouble (P = .015), liability (P = .009), effect on departmental reputation (P = .006), and embarrassment (P < .001) than their colleagues. Regression analysis identified embarrassment among physicians as a critical barrier. If not embarrassed, participants were 2.5 and 4.5 times more likely to report minor errors and major near-miss events, respectively. All members of the radiation oncology team observe errors and near-misses. Physicians, however, are significantly less likely to report events than other colleagues. There are important, specific barriers to physician reporting that need to be addressed to encourage reporting and create a fair culture around reporting.

Radio-chemotherapy in anal cancer: Institutional experience at a large radiation oncology center in Chile

AimIn this article the aim is to provide a concise narrative review and inform the institutional experience at a referral center in Chile with the use of radio-chemotherapy in anal cancer. BackgroundCancer of the anus and anal canal is mainly a loco-regional disease. For years the standard of care has been concomitant radio-chemotherapy, which permits organ preservation and better local control than alternative surgical procedures. Materials and methodsA retrospective analysis of 44 patients treated between 2002 and 2010 was performed. Local recurrence, distant recurrence and overall survival were analyzed with the Kaplan–Meier method. Relevant groups where compared with the log-rank test and univariate analysis were done with the Cox proportional hazards model. ResultsMedian follow-up of the cohort was 56 months, with a minimum follow-up of at least 24 months. There was a significant difference between clinical stages in disease free survival (log-rank trend p<0.001), and a significant difference in overall survival (OS) when comparing clinical stages that were grouped in stage I–IIIa and IIIB (log-rank p=0.001). On univariate analysis, age older than 60, having received full treatment and dose above 45Gy were all significantly related to OS (p<0.05). An overall survival of 45% and disease free survival of 45% at 5 years were found in our series. ConclusionsOur findings show that results at the Instituto de Radiomedicina in Chile are comparable to published literature. Dismal results in stage IIIb cases indicate much work remains in therapies to achieve loco-regional control in locally advanced cases.

Development, Implementation, and Compliance of Treatment Pathways in Radiation Medicine

Introduction: While much emphasis on safety in the radiation oncology clinic is placed on process, there remains considerable opportunity to increase safety, enhance outcomes, and avoid ad hoc care by instituting detailed treatment pathways. The purpose of this study was to review the process of developing evidence and consensus-based, outcomes-oriented treatment pathways that standardize treatment and patient management in a large multi-center radiation oncology practice. Further, we reviewed our compliance in incorporating these directives into our day-to-day clinical practice.Methods: Using the Institute of Medicine guideline for developing treatment pathways, 87 disease specific pathways were developed and incorporated into the electronic medical system in our multi-facility radiation oncology department. Compliance in incorporating treatment pathways was assessed by mining our electronic medical records (EMR) data from January 1, 2010 through February 2012 for patients with breast and prostate cancer.Results: This retrospective analysis of data from EMR found overall compliance to breast and prostate cancer treatment pathways to be 97 and 99%, respectively. The reason for non-compliance proved to be either a failure to complete the prescribed care based on grade II or III toxicity (n = 1 breast, 3 prostate) or patient elected discontinuance of care (n = 1 prostate) or the physician chose a higher dose for positive/close margins (n = 3 breast).Conclusion: This study demonstrates that consensus and evidence-based treatment pathways can be developed and implemented in a multi-center department of radiation oncology. And that for prostate and breast cancer there was a high degree of compliance using these directives. The development and implementation of these pathways serve as a key component of our safety program, most notably in our effort to facilitate consistent decision-making and reducing variation between physicians.

An Evaluation of Departmental Radiation Oncology Incident Reports: Anticipating a National Reporting System

Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS). All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface. Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface. A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.