A combination of approximately six common quality assurance (QA) measures would have prevented more than 90% of 290 errors almost committed during the administration of cancer radiotherapy.
According to a statement describing information presented by Eric Ford, PhD, at the joint American Association of Physicists in Medicine and Canadian Organization of Medical Physicists annual meeting—held in Vancouver, Canada, July 31, 2011, through August 4, 2011—radiation oncologists use more than a dozen QA checks to prevent radiotherapy errors. Ford, himself an assistant professor of radiation oncology and molecular radiation sciences at Johns Hopkins Medical Institutions in Baltimore, Maryland, worked with other researchers at Hopkins and at Washington University in St. Louis, Missouri, to gather data on approximately 4,000 near-miss events that occurred over the course of 2 years at the two institutions.
After narrowing down the data set to 290 potentially serious events that were noticed and corrected before patients suffered any harm, the investigators determined for each commonly used QA check the percentage of these incidents that could have been avoided.
More than 90% of the events would have been stopped with the use of six QA measures. “While clinicians in this field may be familiar with these quality assurance procedures, they may not have appreciated how effective they are in combination,” observed Ford in the statement.
One key to safety proved to be a checklist of relatively low-tech measures, such as having both physicians and radiation-physicists review a patient’s chart prior to treatment to be sure the proper dose of radiation is being delivered. However, cautioned Ford, “[This is] assuming [the checklist is] used consistently correctly, which it often isn’t.”