Patient Safety in Radiation Oncology Welcome and Introduction

Joanne CunninghamGeoff Delaney

Why patient safety?

“First do no harm”...

Recent studies Acute care Radiation oncology

Study / Country Definition of A E Sample Adverse Events

ACUTE CARE -- RETROSPECTIVE CASE RECORD ANALYSIS

US (1984) Harvard Medical Practice

Study

Death/serious disability

30121 pt records;51 acute hospitals

NY State

2.9-3.7% of admissions;

70% preventable

Quality in Australian

Healthcare Study (1991)

Injury14179 pt records;

31 hospitals16.6% of admissions;

51% preventable

UK (1998)Adverse Events in British Hospitals

InjuryPilot study;

1014 2 hospitals

10.8% of admissions; [incl. 3.5%

moderate/serious disability or death]50% preventable

Utah and Colorado Medical Practice

Study (1992)

Death/serious disability

14052 pt records;28 hospitals

2.9% of admissions(50% preventable)

Medical error

Human Cost US 1997, 33.6 million acute admissions => 44,000 to 98,000 patients died due to medical errors (mva 43K, breast ca 42K, AIDs 16K)

Harvard Medical Practice Study

Economic Cost $8.8bn in the US £1bn a year in the UK in terms of additional bed days

alone 8% of all hospital bed days in Australia

Estimates based on sentinel studies

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RADIATION ONCOLOGY EXAMPLES

Author / Journal Methodology ResultsMarks et al; IJROBP 2007;69(5):1579-86 Deviation reporting 0.1%

Huang et al IJROBP 2005;61(5):1590-5 Incident reports, 5 years

1.97%555 reports / 28136 patient treatments

Yeung et al. RO 2005;74:283-91

Incident reports, 10 years4.66%624 incident reports / 13385 patients

Macklis et al. J of Clin Oncology 1998;16:551-6

Transfer errors resulting in incorrect treatment1 year

3.07%59 errors / 1925 patients

Fiorino et al RO 2000;56:85-95

In-vivo dosimetry and Independent check of MU calc & tx chart; No R&V

2.13% of patients with serious systematic error incl. 1.05% >10% dose discrepancy

Calandrino et al RO 1997;45:271-4

In-vivo dosimetry6272 measurementsNo R&V

4.34%70 serious and 147 minor errors / approx 5000 pts

Barthelemy-Brichant et al RO 1999;53:149-54

Experimental approach, disabled R&V- frequency of errors in tx settings (not couch settings)

3.22% of treated fields - (1.17% due to R&V input)

Improvement necessary

“With hindsight, it is easy to see a disaster waiting to happen. We need to develop the capability to achieve the much more difficult - to spot one coming”

DoH UK 2001;An Organisation with a Memory

Safety Culture: system improvement, reporting and learning, compliance, communication

Why patient safety?

Health care = risk to patients Improve the quality of care

delivered to the patient Focus on identification and prevention

of these failures in complex health care systems

Successes E.g. Anaesthesiology, mortality reduced

x20 in past 25 years

ROSIS & Patient Safety

Incidents can have serious consequences in radiotherapy

Information about incidents is generally not shared between radiotherapy departments

Lost opportunities to learn from incidents and prevent injury to future patients

ROSIS established in 2001 To be proactive rather than reactive

Radiation Oncology Practice Standards (Tripartite Agreement)

Aims of this workshop

To assess the impact of mistakes, and methods of prevention, detection, and correction

To heighten awareness of the occurrence of incidents and near incidents in radiotherapy

To encourage a culture of openness in relation to incidents, and promote collaboration

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Format

Lectures Discussion time Group exercises and feedback sessions

INTERACTIVE PRACTICAL as well as theoretical

Real-life challenges and solutions!

Feedback

Feedback sheet Fill in (ANONYMOUSLY) as we go

along Feedback on scope, contents,

format and execution Hand in at the end of the workshop

Thanks to our sponsors

GOLD

SILVER

BRONZE

On behalf of........................Welcome!National Organising

Committee Mr Anthony Arnold, NSW Dr Joanne Cunningham,

VIC Prof Geoff Delaney, NSW Dr Dion Forstner, NSW Prof Chris Hamilton, VIC Ms Caryn Knight, NSW Prof Tomas Kron, VIC Ms Legend Lee, NSW Mr Leigh Smith, VIC Ms Natalia Vukolova, NSW Mr David Collier, VIC

Faculty Mr Anthony Arnold, NSW Ms Fifine Cahill, ACT Prof Mary Coffey, IRELAND Dr Joanne Cunningham, VIC Prof Geoff Delaney, NSW Prof Chris Hamilton, VIC Dr Ola Holmberg, AUSTRIA Prof Tomas Kron, VIC Prof Tommy Knöös, SWEDEN Dr James MacKean, QLD Dr Ivan Williams,  VIC