Accreditation a tool to help reduce medical errors. Professor Arthur T Porter PC MD FACR FRCPC FACRO

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1 Accreditation a tool to help reduce medical errors Professor Arthur T Porter PC MD FACR FRCPC FACRO

2 Errors in Radiotherapy Radiation therapy is a highly regulated medical practice with historically low error and injury rates. Rare instances of radiation therapy errors resulting in severe injuries have been documented. These errors can result in devastating and sometimes fatal injuries, especially when the misadministration results in injury to vital organs or structures, such as the spinal cord, heart, lungs, or brain. Delivering radiation therapy is a team effort requiring collaboration and clear communication between the radiation oncologist, medical physicist, dosimetrist, and radiation therapist/technologist. As technology advances and computers are routinely used to plan, verify, and deliver radiation therapy, an information technologist may also be included on the team. Preventing errors in the delivery of radiation therapy involves not only understanding and appropriately utilizing new advances in technology, but also utilizing established patient safety procedures that optimize safe healthcare delivery.

3 Misadministrations -a wrong dose of radiation therapy, - delivery of radiation therapy to a wrong site - patients receiving the wrong treatment plan

4 ROSIS Voluntary 600 cases from 19 Countries 294/ 600 data transfer issue 130/294 dose error 50% at chart check 35% at treatment

5 Technologically sophisticated therapy IMRT IGRT Tomotherapy Volumetric arc therapy Stereotactic radiosurgery Proton therapy

6 Computer controlled delivery systems (1) make treatment delivery more efficient (2) improve accuracy of treatment (3) make new and more complex treatment modalities, such as intensity modulated radiation therapy, possible even as facilities continue to try to improve cost efficiency

7 Reducing Radiation Therapy Errors through Emerging Technology The manual processes of planning and delivering radiation therapy are being replaced by computerized systems for electronic order entry, treatment plan development, and review and verification of coordinates at the time of treatment.

8 Issues Error rates of 0.21% for all manually treated cases and an error rate of 0.085% for all computer-controlled cases. (McGill) While computer-controlled treatment plans reduce the rate of random treatment delivery errors, they may be susceptible to systematic errors, which may be hard to detect Inadequate staff experience, or training

9 The ACRO process Website Medical Chart Review On site visit Physics Administration Report Accreditation determination

10 The RT Process Consultation: Informed consent: Physician simulation orders: Simulation and set up Dose calculation and/or computer planning: Radiation Treatment Delivery: Dose verification Radiation treatment management: Follow up

11 Clinical Performance Measures: The following clinical documents should be part of each patient s record, and will be reviewed as part of the chart audit: Histopathologic diagnosis Site of disease (or ICD 9 code) Stage of disease Pertinent history and physical examination performed by a Radiation Oncologist Treatment plan Documentation of informed consent to treatment Simulation record, when applicable Dosimetry calculations Graphic treatment plan (e.g. isodose distribution and DVH) when applicable Daily/weekly/total radiation therapy dose and treatment volume records Weekly record of Radiation Oncologist s treatment management Continuing weekly medical physics review Port image(s) documenting each treatment field, when applicable Record of brachytherapy or radionuclide therapy procedure(s), when applicable Treatment summary note Follow-up plan

12 Medical aspects of the ACRO process Documentation CQI Chart reviews Tumour Boards Peer review M and M reviews

13 Chart Reviews Accelerated Partial Breast Irradiation (APBI) Chart Review Breast Cancer Chart Review Gynecologic Cancer - Brachytherapy Chart Review Gynecologic Cancer Chart Review Lung Cancer Chart Review Lung Cancer SBRT Chart Review Neuro-Oncology Chart Review Palliative Cancer Chart Review Prostate Brachytherapy Chart Review Prostate Cancer Chart Review Rectal Cancer Chart Review

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15 Significant Radiation incidents the Caribbean experience Country Date Problem Outcome Costa Rica 1996 Source callibration deaths Panama 2000 New Treatment Computer 28 5 deaths Bahamas 2001 Linac callibration 60 2 deaths Trinidad 2011 Linac callibration 140 >4 deaths Jamaica 2012 Source callibration?

16 A Caribbean Network

17 ACRO certification 2006, 2009 and 2012

18 Peer Review RO to RO on what, why and HOW Must be done early enough to ensure relevance Needs more than one physician Solution Virtual GoToMeeting approach Weekly no fail Between 3 6 BC Radiation Oncologists participate

19 Peer Review

20 Summary Reduction of product variability Standards Real time evaluation External validation

21 Thank you!