TY - JOUR
T1 - Quality assurance with plan veto
T2 - Reincarnation of a record and verify system and its potential value
AU - Noel, Camille E.
AU - Gutti, Veerarajesh
AU - Bosch, Walter
AU - Mutic, Sasa
AU - Ford, Eric
AU - Terezakis, Stephanie
AU - Santanam, Lakshmi
N1 - Funding Information:
Partial funding for this work was provided by Varian Medical Systems .
Copyright:
Copyright 2020 Elsevier B.V., All rights reserved.
PY - 2014/4/1
Y1 - 2014/4/1
N2 - Purpose To quantify the potential impact of the Integrating the Healthcare Enterprise-Radiation Oncology Quality Assurance with Plan Veto (QAPV) on patient safety of external beam radiation therapy (RT) operations. Methods and Materials An institutional database of events (errors and near-misses) was used to evaluate the ability of QAPV to prevent clinically observed events. We analyzed reported events that were related to Digital Imaging and Communications in Medicine RT plan parameter inconsistencies between the intended treatment (on the treatment planning system) and the delivered treatment (on the treatment machine). Critical Digital Imaging and Communications in Medicine RT plan parameters were identified. Each event was scored for importance using the Failure Mode and Effects Analysis methodology. Potential error occurrence (frequency) was derived according to the collected event data, along with the potential event severity, and the probability of detection with and without the theoretical implementation of the QAPV plan comparison check. Failure Mode and Effects Analysis Risk Priority Numbers (RPNs) with and without QAPV were compared to quantify the potential benefit of clinical implementation of QAPV. Results The implementation of QAPV could reduce the RPN values for 15 of 22 (71%) of evaluated parameters, with an overall average reduction in RPN of 68 (range, 0-216). For the 6 high-risk parameters (>200), the average reduction in RPN value was 163 (range, 108-216). The RPN value reduction for the intermediate-risk (200 > RPN > 100) parameters was (0-140). With QAPV, the largest RPN value for "Beam Meterset" was reduced from 324 to 108. The maximum reduction in RPN value was for Beam Meterset (216, 66.7%), whereas the maximum percentage reduction was for Cumulative Meterset Weight (80, 88.9%). Conclusion This analysis quantifies the value of the Integrating the Healthcare Enterprise-Radiation Oncology QAPV implementation in clinical workflow. We demonstrate that although QAPV does not provide a comprehensive solution for error prevention in RT, it can have a significant impact on a subset of the most severe clinically observed events.
AB - Purpose To quantify the potential impact of the Integrating the Healthcare Enterprise-Radiation Oncology Quality Assurance with Plan Veto (QAPV) on patient safety of external beam radiation therapy (RT) operations. Methods and Materials An institutional database of events (errors and near-misses) was used to evaluate the ability of QAPV to prevent clinically observed events. We analyzed reported events that were related to Digital Imaging and Communications in Medicine RT plan parameter inconsistencies between the intended treatment (on the treatment planning system) and the delivered treatment (on the treatment machine). Critical Digital Imaging and Communications in Medicine RT plan parameters were identified. Each event was scored for importance using the Failure Mode and Effects Analysis methodology. Potential error occurrence (frequency) was derived according to the collected event data, along with the potential event severity, and the probability of detection with and without the theoretical implementation of the QAPV plan comparison check. Failure Mode and Effects Analysis Risk Priority Numbers (RPNs) with and without QAPV were compared to quantify the potential benefit of clinical implementation of QAPV. Results The implementation of QAPV could reduce the RPN values for 15 of 22 (71%) of evaluated parameters, with an overall average reduction in RPN of 68 (range, 0-216). For the 6 high-risk parameters (>200), the average reduction in RPN value was 163 (range, 108-216). The RPN value reduction for the intermediate-risk (200 > RPN > 100) parameters was (0-140). With QAPV, the largest RPN value for "Beam Meterset" was reduced from 324 to 108. The maximum reduction in RPN value was for Beam Meterset (216, 66.7%), whereas the maximum percentage reduction was for Cumulative Meterset Weight (80, 88.9%). Conclusion This analysis quantifies the value of the Integrating the Healthcare Enterprise-Radiation Oncology QAPV implementation in clinical workflow. We demonstrate that although QAPV does not provide a comprehensive solution for error prevention in RT, it can have a significant impact on a subset of the most severe clinically observed events.
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U2 - 10.1016/j.ijrobp.2013.12.044
DO - 10.1016/j.ijrobp.2013.12.044
M3 - Article
C2 - 24661669
AN - SCOPUS:84897856421
SN - 0360-3016
VL - 88
SP - 1161
EP - 1166
JO - International Journal of Radiation Oncology Biology Physics
JF - International Journal of Radiation Oncology Biology Physics
IS - 5
ER -