Room: Exhibit Hall | Forum 7
Purpose: This work aims to quantify the process improvement accomplished by using procedure and computer assisted chart check after the treatment planning system (TPS) transition.
Methods: The process review events and critical near-miss events reported in our departmental incident learning system are reviewed in monthly basis and actions are taken based on the error analysis. In the month of TPS transition, treatment planning related events reported in our departmental incident learning system increased about 7 times. Procedures and software (Computer-Assisted-Chart-Checking-and-Inspection, CACCI) were developed for process improvement. The reported events in our departmental incident learning system were utilized to quantify the improvements.
Results: Among the 490 process review events and 69 critical near-miss events collected in 2017, treatment planning process related error was 27% (n=151). 68% of planning related events were chart setup issues occurring at Mosaiq chart preparation. 22% events were treatment planning related and 10% events were communication related. 99% of planning related errors did not impact patient dose delivery, but, increased the stress or delayed the clinical workflow. A significant trend of error reduction was observed after the procedure and checklist were implemented and 6-month average was 12.3 events/month. However, there were still 80% of errors were chart setup related. The implementation of CACCI further reduced the chart setup related errors effectively and the 3-month average was 6.7 events/month.
Conclusion: We found the biggest barrier for a seamless transition was the compatibility between hardware/software from different vendors. Procedure guidance and computer assisted chart checking effectively improved the treatment planning and chart preparation process.
Treatment Planning, Quality Control
Not Applicable / None Entered.