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Implementation of SBRT Guidelines and Evaluating Their Effectiveness Via Incident Learning Across Multiple Institutions

R McGurk1*, K Woch Naheedy2,3, T Kosak4, K C Paradis2,3, M Kearney4, J Moran2,3, B Mullins1, R Mak4, L Mazur1 (1) University of North Carolina at Chapel Hill, Chapel Hill, NC, (2) University of Michigan Medical Center, Ann Arbor, MI, (3) The University of Michigan, Ann Arbor, MI, (4) Brigham and Women's Hospital and Dana-Farber Cancer Center, Boston


(Sunday, 7/12/2020) 3:30 PM - 4:30 PM [Eastern Time (GMT-4)]

Room: Track 3

Stereotactic body radiation therapy (SBRT) techniques can improve therapeutic ratios and patient convenience but their higher dose per fraction and fewer fractions increase the risk of harm to the patient if mistakes are made during treatment planning or delivery. To maximize SBRT treatment quality and patient safety, this study analyzed the implementation of recommendations from national guidance documents together with incidents submitted to an incident learning system (ILS) to assess both effective and ineffective safeguards.

For the three institutions, 150 SBRT incidents were reported locally during 2015-2019 and reviewed in a common ILS. Incidents were analyzed using customized care paths describing the process from initial patient consult to treatment completion. Certain steps were designated as safeguards; independent steps designed to prevent errors from reaching patients. Incidents reaching the patient were assigned a severity score based on the scale used in the AAPM Task Group 275 Report. A simplified Human Factor Classification System (HFACS) was used to analyze the failure of relevant safeguards.

61 of 150 incidents were determined to have reached the patient (40.7%) with 57 low-severity and 4 medium-severity. Most incidents originated in the treatment planning stage (36.1%) and most were caught during the pre-treatment review and verification stage (42.4%). HFACS classification revealed that safeguard failures were attributable to human error (94.9%), routine violations (4.5%), and exceptional violations (0.6%). Underlying preconditions leading to safeguard failures were found to be personnel factors (e.g., suboptimal communication, documentation) 34.4% of the time, and operator condition (e.g., time pressure, distractions, high workload) 29.5% of the time.

With 40.7% of SBRT incidences reaching the patient, there is a continued need for improved robustness and availability of QA safeguards. Strategies which address improving communication and documentation, time pressures, distraction, and high workload may provide the best approach for further improvements.

Funding Support, Disclosures, and Conflict of Interest: Drs. Mazur and McLeod have a financial relationship (eg, royalties and equity) with CommunifyHealth, which provides software for incident reporting and analysis


Operations Research


TH- Radiation Dose Measurement Devices: 3D solid gel/plastic

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