Purpose: Surface-guided radiation therapy (SGRT), while most useful for patient positioning and motion management during radiotherapy, can also improve safety and quality by acting as an “independent observer” during treatment. This study uses multiple incident learning systems (ILS) to identify the types and frequency of errors that could potentially be avoided by implementing SGRT in the clinic.
Methods: Three ILS were retrospectively mined to categorize and quantify errors that could have been prevented with SGRT. As the availability of technology and types of errors may vary across practices, the ILS represented international (SAFRON, IAEA), regional (AvIC, Sweden), and institutional (UW-ILS, USA) databases. General incident categories relevant for SGRT were identified and used to search events. Each event was reviewed individually and assigned to the relevant Incident categories if considered preventable with SGRT. The severity of SGRT-related events was investigated.
Results: A total of 179 events were identified to be preventable with SGRT, representing 21% of reports at the verification/treatment stage. The most common events were wrong isocenter (43%) and wrong immobilization (34%). The distribution of event types was similar between the UW-ILS and SAFRON databases. AvIC had a smaller absolute number of events and immobilization-related events, which was attributed to the widespread use of SGRT in Sweden. Severity data indicated that SGRT-preventable events tend to have high severity scores.
Conclusion: To our knowledge this is the first study of its type to study the value of SGRT in error prevention. Errors related to the wrong isocenter and immobilization are the most common pathways that could be detected with SGRT. By reducing misalignments and monitoring the entire treatment process, SGRT has the potential to be a valuable tool for increasing patient safety in radiotherapy.