USING INCIDENT LEARNING IN RADIATION THERAPY: THE FIRST-HAND EXPERIENCE IN A LOW-INCOME SETTING USING CUTTING-EDGE TECHNOLOGY

Authors

  • Addison Eric. C. D. K
  • Yankson Ruth
  • Ngoah Amos
  • Boakye F
  • Preko K

DOI:

https://doi.org/10.47672/ejps.902

Keywords:

Incidents, Near-misses, Non-Conformance, Error, Radiotherapy Settings.

Abstract

Objective: To explore the implementation of an incident learning system for quality management of radiotherapy in a low-income radiotherapy setting.

Materials and Methods: An incident learning system was specifically designed using the human-centred design, the waterfall model was implemented for error identification and learning of individual incidents. The incidents that occurred in external beam radiotherapy for 8 years, were reported.

Results and Discussion: A total of 122 incidents, 49 Near-misses and 28 non-conformance were identified with 4465 patients treated within the 8 years. The total average percentage of 2.73, 1.10, 0.63 and 4.46 were detected for incidents, near miss and non-conformance respectively. The average incident, near miss and non-conformance rate per 100 patients treated were 2.73, 1.10 and 0.63 respectively over the 8-years review period. The highest wrong total dose error of 79 occurred in the eighth year. Trend analysis identifies major improvements in clinical practice by measuring and analyzing patterns of incidents over time. The trending incident levels for each treatment site were in decreasing order of level 4, level 1, level 2, level 5, and level 3.

Conclusion: Treatment status gave an overview of the quality of clinical decisions and implementation in the management of radiotherapy patients. Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety.

Recommendation: Future iterations, would improve the error tagging and solution recommendation parts, and extend the implementation all radiotherapy centres in the country.

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Author Biographies

Addison Eric. C. D. K

Physics Department, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Oncology Directorate, Komfo Anokye Teaching Hospital, Kumasi, Ghana.

Yankson Ruth

Computer Science Department, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Ngoah Amos

Computer Science Department, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Boakye F

Physics Department, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

Preko K

Physics Department, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana.

References

A. Arnold, G. P. Delaney, L. Cassapi, and M. Barton, "The use of categorized time-trend reporting of radiation oncology incidents: a proactive analytical approach to improving quality and safety over time," International Journal of Radiation Oncology Biology Physics, vol. 78, no. 5, pp. 1548-1554, 2010.

B. G. Clark, R. J. Brown, J. L. Ploquin, A. L. Kind, and L. Grimard, "The management of radiation treatment error through incident learning," Radiotherapy & Oncology, vol. 95, no. 3, pp. 344-349, 2010.

B. W. Cox, A. Sharma, L. Potters, and A. Kapur, "Prospective contouring rounds: a novel, high-impact tool for optimizing quality assurance," International Journal of Radiation Oncology, Biology, and Physics, vol. 87, no. 2, p. S118, 2013.

E. C. Ford, K. Smith, K. Harris, and S. Terezakis, "Prevention of a wrong-location misadministration through the use of an intradepartmental incident learning system," Medical Physics, vol. 39, no. 11, pp. 6968-6971, 2012.

E. C. Ford, L. F. de los Santos, T. Pawlicki, S. Sutlief, and P. Dunscombe, "Consensus recommendations for incident learning database structures in radiation oncology," Medical Physics, vol. 39, no. 12, pp. 7272-7290, 2012.

E. C. Ford, S. Terezakis, A. Souranis, K. Harris, H. Gay, and S. Mutic, "Quality control quantification (QCQ): a tool to measure the value of quality control checks in radiation oncology," International Journal of Radiation Oncology Biology Physics, vol. 84, no. 3, pp. e263-e269, 2012.

E. U. Ekaette, R. C. Lee, D. L. Cooke, K. Kelly, and P. B. Dunscombe, "Risk analysis in radiation treatment: application of a new taxonomic structure," Radiotherapy and Oncology, vol. 80, no. 3, pp. 282-287, 2006.

F. Rath, "Tools for developing a quality management program: proactive tools (process mapping, value stream mapping, fault tree analysis, and failure mode and effects analysis)," International Journal of Radiation Oncology Biology Physics, vol. 71, no. 1, pp. S187-S190, 2008.

J. Bissonnette and G. Medlam, "Trend analysis of radiation therapy incidents over seven years," Radiotherapy and Oncology, vol. 96, no. 1, pp. 139-144, 2010.

J. Cunningham, M. Coffey, T. Kno¨os, and O. Holmberg, "Radiation oncology safety information system (ROSIS)"”profiles of participants and the first 1074 incident reports," Radiotherapy and Oncology, vol. 97, no. 3, pp. 601-607, 2010.

L. J. Peters, B. O'Sullivan, J. Giralt et al., "Critical impact of radiotherapy protocol compliance and quality in the treatment of advanced head and neck cancer: results from TROG 02.02," Journal of Clinical Oncology, vol. 28, no. 18, pp. 2996-3001, 2010.

M. S. Huq, B. A. Fraass, P. B. Dunscombe et al., "A method for evaluating quality assurance needs in radiation therapy," International Journal of Radiation Oncology Biology Physics, vol. 71, no. 1, pp. S170-S173, 2008.

M. V. Williams, "Improving patient safety in radiotherapy by learning from near misses, incidents and errors," British Journal of Radiology, vol. 80, no. 953, pp. 297-301, 2007.

M. V. Williams, "Radiotherapy near misses, incidents and errors: radiotherapy incident at Glasgow," Clinical Oncology, vol. 19, no. 1, pp. 1-3, 2007.

P. Dunscombe, "Recommendations for safer radiotherapy: what's the message?" Frontiers in Oncology, vol. 2, article 129, 2012.

P. J. Pronovost, C. A. Goeschel, K. L. Olsen et al., "Reducing health care hazards: lessons from the commercial aviation safety team," Health Affairs, vol. 28, pp. w479-w489, 2009.

S. Mutic, R. S. Brame, S. Oddiraju et al., "Event (error and nearmiss) reporting and learning system for process improvement in radiation oncology," Medical Physics, vol. 37, no. 9, pp. 5027- 5036, 2010.

T. K. Yeung, K. Bortolotto, S. Cosby, M. Hoar, and E. Lederer, "Quality assurance in radiotherapy: evaluation of errors and incidents recorded over a 10 year period," Radiotherapy and Oncology, vol. 74, no. 3, pp. 283-291, 2005.

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Published

2022-01-14

How to Cite

Addison, E. C. D. K., Yankson, R., Ngoah, A., Boakye , F., & Preko , K. (2022). USING INCIDENT LEARNING IN RADIATION THERAPY: THE FIRST-HAND EXPERIENCE IN A LOW-INCOME SETTING USING CUTTING-EDGE TECHNOLOGY. European Journal of Physical Sciences, 5(1), 1–13. https://doi.org/10.47672/ejps.902

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