Retrospective Review and Analysis of Treatment Planning Errors
M Joo*, M Lin, A Godley, D Sher, E Chambers, C Wallace, A Pompos, UT Southwestern Medical Center, Dallas, TX
Presentations
PO-GePV-T-141 (Sunday, 7/25/2021) [Eastern Time (GMT-4)]
Purpose: Our department performs regular process review as part of the quality improvement efforts. The goal of this study was (1) to retrospectively analyze treatment planning- and chart setup-related errors in a controlled sub-sample of patients and (2) to identify potential sources of these errors to reduce and avoid future occurrences.
Methods: To ensure consistency and accuracy of data statistics, a complete set of treatment plans, which were checked by a single physicist over a 7-month period, was included in the study. The plans, in which no errors were found, consist the control sample, while the rest of the plans, where errors were found by the physicist or other staff involved in the patient care, define the variance sample. Errors related to treatment planning and chart setup were analyzed. Analysis metrics included hypothesized correlations of various timelines along the treatment planning process with error rate. Significant difference between the control and variance groups was investigated.
Results: 207 plans in the control group and 115 reported errors in the variance group were analyzed. No significant difference was observed between the control and variance groups in errors occurring at various time points. The variance group had a slightly larger fraction of plans that violated our planning timeline (0.42 vs. 0.39) and a larger fraction of plans that had a shorter timeline between patient simulation and the start of treatment. Planning efficiency and planner variable were found not to be factors in clinical errors.
Conclusion: The results did not find any correlation between the control sample and the variance sample with respect to the treatment planning timelines. As continuous review of adverse events helps improve clinical processes and prevents future similar errors, further examination is needed to investigate other root causes of the errors.
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