R Larouche*, N Lahaie, A Veillette, T Vu, S Michalowski, Centre hospitalier de l'Universite de Montreal(CHUM), Montreal, QC, CA,

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  R Larouche

PO-GePV-T-140 (Sunday, 7/25/2021)   [Eastern Time (GMT-4)]

Purpose: In 2020, 16% of the incident reports submitted to our Incident Learning program were related to Radiotherapy prescriptions. As these are a critical part of Radiotherapy treatments, a large amount of resources and time are invested within our department to check for and correct these issues before treatment starts. We decided to investigate in further detail the error rates, and their causes to better understand the quality of Radiotherapy prescriptions and how to improve it.

Methods: We used three different methods to measure and investigate Radiotherapy prescription errors: first, we reviewed past incident reports to find all reports related to Radiotherapy prescriptions; second, we organised a two-week survey to identify and quantify the type and number of issues with Radiotherapy prescriptions; third, a chart audit of 100 targeted patients was done to identify any unreported errors. Patient selection was done purposefully to ensure that all Radiation Oncologists, treatment sites, techniques and modalities were represented within the audit.

Results: Whereas the incident reports represented 2.3% of Radiotherapy prescriptions treated in our department in 2020, the survey identified 13 radiotherapy prescriptions having errors out of 135 investigated (9.6%), and the audit identified 20 radiotherapy prescriptions having errors out of 100 investigated (20%). We categorized the errors for the survey and audit investigations, noticing that most of the errors that could have led to treatment errors where associated with treatment sequencing and treatment site identification.

Conclusion: The important number of reports submitted to our Incident Learning program alerted the team to investigate prescription errors, but it was clearly underreporting the importance of these issues despite being a highly functional program. We hope to review and improve our processes with a Failure Modes and Effect Analysis, making sure to repeat our survey and audit experiments to measure the outcomes of any process changes.

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Keywords

Systematic Errors, Quality Assurance

Taxonomy

Not Applicable / None Entered.

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