Background: Safety initiatives in the United States continue to work on providing guidance as to how the average practitioner might make patients safer in the face of the complex process by which radiation therapy (RT), an essential treatment used in the management of many patients
with cancer, is prepared and delivered. Quality control measures can uncover certain specific errors such as machine dose miscalibration or misalignments of the patient in the radiation treatment beam. However, they are less effective at uncovering less common errors that can occur anywhere
along the treatment planning and delivery process, and even when the process is functioning as intended, errors still occur. Prioritizing Risks and Implementing Risk-Reduction Strategies: Activities undertaken at the radiation oncology department at the Johns Hopkins Hospital (Baltimore)
include Failure Mode and Effects Analysis (FMEA), risk-reduction interventions, and voluntary error and near-miss reporting systems. A visual process map portrayed 269 RT steps occurring among four subprocesses—including consult, simulation, treatment planning, and treatment delivery.
Two FMEAs revealed 127 and 159 possible failure modes, respectively. Risk-reduction interventions for 15 “top-ranked” failure modes were implemented. Since the error and near-miss reporting system's implementation in the department in 2007, 253 events have been logged. However,
the system may be insufficient for radiation oncology, for which a greater level of practice-specific information is required to fully understand each event. Conclusions: The “basic science” of radiation treatment has received considerable support and attention in developing
novel therapies to benefit patients. The time has come to apply the same focus and resources to ensuring that patients safely receive the maximal benefits possible.
Document Type: Research Article
Publication date: July 1, 2011
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Published monthly, The Joint Commission Journal on Quality and Patient Safety is a peer-reviewed publication dedicated to providing health professionals with the information they need to promote the quality and safety of health care. The Joint Commission Journal on Quality and Patient Safety invites original manuscripts on the development, adaptation, and/or implementation of innovative thinking, strategies, and practices in improving quality and safety in health care. Case studies, program or project reports, reports of new methodologies or new applications of methodologies, research studies on the effectiveness of improvement interventions, and commentaries on issues and practices are all considered.
Also known as Joint Commission Journal on Quality Improvement and Joint Commission Journal on Quality and Safety