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Analysis of SBRT Planning and Delivery Incidences Via Customized Process Mapping

R McGurk1*, B Mullins1, A Amos1, D Gu1, B Chera1, L Marks1, S Das1, L Mazur1,2,3 1. School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 2. School of Information and Library Science, University of North Carolina, Chapel Hill, NC 3. Carolina Health Informatics Program, University of North Carolina, Chapel Hill, NC


(Sunday, 7/14/2019) 4:00 PM - 5:00 PM

Room: 301

Purpose: Stereotactic body radiation therapy (SBRT) is a complex procedure, with multiple steps/handoffs involving diverse groups of clinical staff. We created a formal process map (care-path), and a system to prospectively report incidents (i.e. errors in that process). We herein analyze these events as part of an ongoing quality improvement effort to improve patient safety, as recommended by AAPM TG-101.

Methods: We created a care-path comprising steps from patient registration to treatment completion for SBRT treatments at our institution. Certain steps were designated as safeguards; i.e. points where independent checks of prior steps are performed. Staff prospectively submitted reports of incidents (when identified) to our internal Incident Learning System (e.g. human errors during patient registration, CT-simulation imaging, treatment planning, delivery, and non-compliance with institution policies). Each reported incident was categorized based on where on the care-path the incident initiated, which safeguards were crossed (i.e. that did not catch the incident), and where it was caught. A modified human factor engineering classification system (HFACS) identified contributing factors for human errors associated with crossed safeguards for each incident.

Results: Analysis was completed for 25 incidents reported between January 2016-January 2019. The CT-simulation and treatment planning phases contributed most of the incidents (15/25). The number of safeguards crossed ranged from 1-8 (mean 1.7, standard deviation 1.8). The physics pre-treatment check safeguard was found to be simultaneously the most effective (4/25 incidents caught) and least effective (7/25 incidents crossed). Contributing factors for incidents included suboptimal documentation, time pressures and software technical limitations. No incident studied resulted in a medical event.

Conclusion: This work provides an estimate for the effectiveness of our existing safeguards to catch incidents/errors and thus identifies opportunities for improvement. The long term goal is to develop an efficient care-path with effective safeguards that catch the most relevant errors with SBRT.


Statistical Analysis, Risk, Quality Control


Not Applicable / None Entered.

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