Patient Safety in the Spotlight for #PSAW20

By Matt Spraker, MD, PhD, @SprakerMDPhD

Patient Safety Awareness Week, an annual celebration of patient safety and quality improvement initiatives, took place this year on March 8-14. Even in the midst of the COVID-19 global outbreak, radiation oncology professionals took to social media (#PSAW20) to highlight their dedication to delivering safe and high-quality radiation therapy to their patients. Some took a more traditional approach and highlighted their important contributions to patient safety. Dr. Tom Boike (@TomBoike) shared that he was out on an APEx accreditation survey, and Dr. Louis Potters (@DrPotters) showed a new chapter of Dr. Leonard Gunderson’s textbook focused on patient safety and quality improvement. Others decided to push the envelope with the latest trends. Quality and safety expert radiation oncologist Dr. Sue Evans (@SueEvansMDMPH) shared our field’s first TikTok video that showcases Yale’s patient safety efforts while rocking out to the internet’s most famous safety song “I Wanna be Safe” by Derek Wilson.

Tweet from Christiana Care during #PSAW20One of the most discussed topics was RO-ILS: Radiation Oncology Incident Learning System®. This multi-center database stores data about unsafe conditions and patient safety incidents in radiation oncology with a patient safety organization to facilitate shared learning and quality improvement in a secure, non-punitive environment. The program has been sponsored by ASTRO and the AAPM as well as supported by numerous industry partners and sister societies. During #PSAW20, ASTRO (@ASTRO_org) shared RO-ILS in Review, which documents the first five years of experience of the program. RO-ILS has over 500 enrolled facilities from almost every state and has collected reports on over 12,000 safety events and the program continues to grow. Oregon Health & Science University (@OHSURadMed) shared that they were implementing RO-ILS just in time for the #PSAW20 celebration! ASTRO also released an APEx in Review report, highlighting the reduction made to the accreditation timeline as a result of programmatic improvements and evidence indicators with low compliance — areas for improvement by our community!

Many #PSAW20 posts highlighted specific strategies that departments have used to improve patient safety. Dr. Evans highlighted a RO-ILS program document on implementing a “Great Catch Program,” which can be used to improve departmental safety culture and support incident reporting. Dr. Eric Ford (@EricFor85220573) shared the “Great Catch” pin, which is awarded to professionals in the Great Catch Program at the University of Washington. Dr. Ann Raldow (@AnnRaldow_MD) shared a video about a collaboration between UCLA, UCSF (@UCSFCancer), and the Richmond VA that uses computer automation to reduce the risk of therapeutic radiation incidents. She also shared another #UCLARadOnc video that discusses 100% prospective peer review for SRS and SBRT treatments. Dr. Elizabeth Covington (@elizapowerpuff) shared two videos on her work with colleagues at University of Alabama regarding a script to reduce shift errors and an open source solution for complying with TG-263 structured naming.

Toward the end of the week, the #PSAW20 discussions urgently shifted focus toward keeping patients and radiation oncology professionals safe during the COVID19 pandemic. On March 14-15, Radiation Nation (@Rad_Nation), led by Drs. Matthew Katz (@subatomicdoc) and Richard Simcock (@BreastDocUK), hosted an urgent radiation oncology journal club on Twitter which drew 121 contributors from around the globe. The discussion focused on four key domains (listed below) and was summarized in a blog post by Dr. Simcock and led to rapid publication of a paper.

Four key domains of the journal club discussion:

  1. How do we deliver treatments with reduced workforce?
    1. Are there ways of working remotely that can still utilize an isolated workforce?
    2. Do we move to more simple plans and/or hypofractionate?
    3. What barriers exist to making these changes urgently?
  2. What risks to our patients can we mitigate?
  3. Should we change/stop/delay certain treatments?
  4. How do we treat a confirmed #COVID case with #radonc?


The international community of radiation oncologists have demonstrated their exceptional commitment to patient safety with their response to the COVID-19 pandemic. Drs. Ramesh Rengan and Ford and their team published a webinar and an editorial with recommendations for clinical management based on early experiences in Seattle. Authors from Italy, Switzerland and China (Wuhan), among others, have shared their lessons learned on how best to keep our patients and ourselves safe in these unprecedented times. Links to these articles and more have been cataloged and shared by ASTRO. ASTRO also released FAQs, clinical and coding guidance and is actively advocating on behalf of the community. As new information emerges, ASTRO continues to collate and develop resources to support our field.

While #PSAW20 occurred in the midst of significant challenges facing our field, radiation oncologists have delivered an inspiring response to help each other keep everybody safe. When clinical operations return to normal, I hope that we can apply all we have learned to continue to optimize patient safety and quality improvement for all of our patients across the world.

Posted: April 6, 2020 | with 0 comments
Filed under: Patient Safety

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