Crowd-Sourcing Solutions to Common Problems

A question for those of us who work in Radiation Oncology clinics: does it ever happen that when therapists go to set up a patient, that their instructions for shifting from the original set up point are wrong? Or that the reference images used for IGRT are wrong in some way? Something went awry upstream, slipped through the checks, and wrong information made it to the machine? Most of us have seen this, and based on RO-ILS data, this type of error is uncomfortably common. Wouldn't it be useful to have a way to share experiences and (importantly) solutions?

A new AAPM Task Group has been formed to try a new approach to sharing solutions to common problems, with this “wrong shift information” being the test case. TG-327, “Crowd-sourced solutions to the problem of wrong shift instructions”, will use a forum on the AAPM BBS as the platform, “Common Error Pathways.” To get there, log into the AAPM website, click on the BBS link, and scroll to the bottom. (See screenshots below.) Or, knock wood, use this link.

We have posted there a number of common pathways that have different precipitating events but all result in the “wrong shift information” problem. For example, here are three:

• Pathway 1: Patient marked incorrectly in sim
• Pathway 3: IGRT reference images created from wrong dataset
• Pathway 5: Shift instructions manually calculated or transcribed incorrectly

When you open one of the pathway postings, you see a more complete description: precipitating event, description of the normal workflow, how the event creates an error, and existing QC steps that failed. We invite people to look though these pathways and if your clinic has seen one or something similar and have implemented a solution, then share that.

How to share? Here is the strength and weakness of this experiment: you can't post directly to the BBS. We ask that you talk with one of the TG members by phone, have a conversation, to describe your experience and recommendation. The TG member will then post the response, extending the thread under the pathway. You can see an example under Pathway 1. We chose to use this indirect approach for two reasons. One is to ensure that the information is complete and clear. The other is to provide anonymity to responders, which is a concern for some when sharing information about errors. The contact information (phone numbers and emails) are in the first posting in the BBS forum. We have TG members spanning the US.

Also, if you have encountered a pathway not already described, you can contact a TG member and have that added to the forum.

How will solutions be disseminated? AAPM members can monitor the BBS and look at replies to any error pathway that is relevant to them. (You can be notified of new postings by subscribing to the forum via the Control Panel—see below.) Ultimately, we will move all the information to the new AAPM safety web page.

Will this work? We will see — this is an experiment. Whether this works depends primarily on AAPM members taking the time to engage with this community process. We are using the BBS because it is there, but if there is sufficient response to this trial then we can create a specific tool for crowd-sourcing. Because posting on this forum is limited to TG members, we have a second forum in the same space open to all so people can comment on the process and, importantly, if they find something useful.

Participation is key, so we will be using multiple means to publicize this effort. Also, this could be a productive topic for a chapter meeting, and funding might be available for a TG member to attend.

Spread the word and help each other out.

TG-327 members
Gary Ezzell (Arizona)
Sheri Weintraub (Massachusetts)
Ryan Manger (California)
Grace Kim (California)
Debbie Schofield (Florida)
Jackie Faught (Tennessee)

Here are some screenshots illustrating how to access the BBS forum and subscribe to updates.