^

ASTRO Blog

ASTRO Blog

It’s a Celebration: One Practice’s Activities for Patient Safety Awareness Week

By Tara Kosak, MEd, RT(T)(CT) and Meghan Kearney, MS, Quality and Safety Program Managers

March 12-18 marks National Patient Safety Awareness Week (PSAW), an opportunity for health care organizations to celebrate the important work being done every day to improve patient and staff safety and a platform to promote awareness.

The Department of Radiation Oncology at Dana-Farber Brigham Cancer Center uses PSAW as a way to reinforce our strong safety culture within the department and to educate staff about current efforts and initiatives related to patient safety. Last year, Dana-Farber Brigham Cancer Center celebrated the week with a variety of activities including:

  1. A daily enewsletter, featuring frontline staff messages from various members of the radiation oncology team about “what safety means to me.” The messages were accompanied by safety selfies of staff holding ASTRO's #PSAW22 sign.

    Example of a staff message [edited for length]:

    • “As we celebrate National Patient Safety Awareness Week, I want to applaud our department for creating a strong safety culture… We rely on each other to provide every patient the highest level of care and safety. I encourage each one of us to celebrate the work we have done to ensure we deliver safe and high-quality care to all our patients and identify ways to improve patient safety.”
     
    • “As medical dosimetrists, safety is always our utmost priority, for our colleagues and especially for our patients... As a group, we often collaborate to improve our efficiency and ensure that every patient receives safe, compassionate care. We are fortunate to work in a department that promotes a culture of open discourse and actively tries to improve upon that culture. These acts of quality care should be celebrated as a reflection of the diligence and conscientious staff this department has accumulated, as well as a reflection of the organization as a whole.”
 
  1. Safety-focused quizzes and surveys were embedded within the daily newsletter and staff who completed surveys were entered into a daily gift card raffle.

    Examples of surveys:
    • Safety reporting survey to better understand barriers to reporting events
    • Submit a safety initiative
    • Feedback on the departmental quarterly safety newsletter  
    • Just for fun – this or that
    • Patient safety rounds quiz
 
  1. A patient safety rounds forum was held on Equity Informed High Reliability.  
    • Dana-Farber Brigham Cancer Center has been deeply invested in learning about high reliability organizations over the last several years. Staff within quality improvement and clinical operations leadership teams completed online and interactive education through an online learning platform, with the support of Brigham and Women’s Hospital (BWH) Quality & Safety. 
    •  
    • A guest speaker presented at the department’s quarterly patient safety rounds to discuss BWH’s approach to high reliability using an equity informed approach. 
 
  1. All staff received cupcakes in a jar adorned with the department's safety logo.
 
  1. Staff were encouraged to use ASTRO's PSAW virtual meeting background for all virtual meetings and share selfies holding the #PSAW sign.  
 

  1. The department recognized the year’s Great Catch award recipients.  
    • To endorse the culture of safety and continuous learning within the department, a Great Catch program was put into place nearly seven years ago to acknowledge individuals and teams that go above and beyond to prevent harm, report an issue that may lead to significant process improvement or identify an issue that is not well understood. 
    •  
    • The Great Catch nominees are voted on by the quality improvement committee on a quarterly basis and winners are awarded with a certificate, showcased in a quarterly safety newsletter and acknowledged at the standing Patient Safety & Process Improvement Rounds. 
 

While PSAW is a week-long opportunity for the department to showcase its pledge to safety, the journey for promoting safety is continuous and evolving. The department is actively planning for PSAW 2023, building on all of the great ideas from past celebrations. This year, the plan is to continue to share messages in a daily enewsletter from frontline staff on how safety impacts their daily work. New this year, we will encourage staff to wear purple in support of safety, host a guest speaker presentation on moral injury and facilitate a design contest. The winning design will become a pin and the official Great Catch award token for past and future Great Catch Award recipients.

Our department is strongly committed to safety reporting and understands that reports are an opportunity to learn and grow, rather than the reflection of unsafe practice. The department currently uses a commercial hospital-wide software platform for safety report submission internally. In addition, we are proud to have officially joined as members of the RO-ILS: Radiation Oncology Incident Learning System® initiative. For years, the department has drawn from the educational resources and aggregate reporting provided by RO-ILS, and we are excited to officially be contributors to the larger radiation oncology community.


What are your plans for 2023 PSAW? Not sure? Now is the time to start planning! ASTRO has provided new fliers for your individual and group safety selfies and a virtual background for #PSAW23. Additionally, ASTRO is collecting stories about patient safety — share your passion with us and the community. We would love to hear how RO-ILS, APEx and your own initiatives have fueled positive change and quality improvement. For more information and to get involved, visit ASTRO’s PSAW webpage.

Share ideas in the comments section and join the conversation about patient safety.

Posted: February 21, 2023 | 0 comments


2021 Safety Error Reporting Trends. Noise or Cause for Concern?

By Suzanne Evans, MD and Sheri Weintraub, PhD

RO-ILS: Radiation Oncology Incident Learning System® releases regular reports and education to the radiation oncology community based on safety events and errors submitted by participating U.S. practices. Aggregate data trends held steady over the past eight years, with expected fluctuations associated with data element changes (e.g., when a data element became required, new answer options were added). That was, until now. The RO-ILS Q4 2021 Aggregate Data Report indicates a striking new trend in 2021 related to the workflow step in which events occurred.

Between 2017 and 2020, when data element 208. Occurred Workflow was required, event occurrence during treatment delivery (including imaging) has traditionally comprised an average of 26% (Figure 1). However, for 2021 that number was 41%. This represents a 58% increase over historical norms. Fewer events were seen to occur in treatment planning and pre-treatment quality assurance (QA) and review, whereas other domains remained stable relative to historical norms.

Figure 1:

Unsurprisingly, the downstream metric for where the event was discovered (207. Discovered_Workflow) similarly shifted to the right, with 29% of events discovered at on-treatment QA compared to a historical average of 11% (Figure 2).

Figure 2:

Why are we seeing this change in RO-ILS data? Did more events actually occur at the linear accelerator (linac) and if so, why? Did fewer errors happen during treatment planning and why might that be the case? Or are there other factors that impact the data?

It is important to understand there are two basic interpretations of this finding: that this is real, or that this is artifactual. Perhaps there really is a shift in where in the workflow errors occurred in 2021 (e.g., more events happened at treatment delivery). Conversely, it could be artifactual — that the events occurring at treatment delivery are stagnant in number, but that we are seeing a relative percentage increase in these events due to selective non-reporting of more upstream events, a risk of any voluntary incident reporting program. Although more analysis is needed, we have some initial thoughts as members of the Radiation Oncology Healthcare Advisory Council (RO-HAC) who review and analyze RO-ILS data.

First, let's consider interpretation 1: More events are happening at treatment delivery, fewer events at other workflow steps. This real trend could either be a positive or negative indicator of safety.

Let’s be optimistic and consider that this is a real trend and is actually a good thing. Perhaps advancement in technology may explain this phenomenon. For example, with the rise of new equipment like surface guided radiation therapy (SGRT), practices may be better able to detect errors occurring during treatment that were otherwise opaque before. SGRT can be very helpful in detecting the improper application of shifts, which has been demonstrated in the RO-ILS data to be a major pathway of significant errors. Additionally, there has been a move toward increased automation of treatment planning processes, which may result in a reduction in errors occurring earlier in the process of care. If enough practices acquired or implemented SGRT and/or knowledge-based planning tools between 2020 and 2021, then this could result in a shift in where in the process events are occurring.

How about the impact of the pandemic? That has certainly brought about a dramatic shift in a short period of time. COVID-19 affected the ability of certain staff members to work from home initially, which then brought on a wave of employees seeking work from home or hybrid arrangements as part of routine practice. As treatment planning can be done remotely, this may have altered the work environment for dosimetrists more than for other members of the radiation oncology team. Are at-home work environments for dosimetrists conducive to higher safety standards, leading to fewer errors in treatment planning?

Importantly, incident learning systems, including RO-ILS, encourage reporting. More events can indicate heightened awareness within that process of care, a strong culture of safety and the desire to address issues, no matter how trivial. Technology advancements such as adaptive radiation therapy are increasing the complexity of treatment delivery. With the adoption of new systems, an increase of events is expected as practices work to perfect processes. More events within a given process could result in an increased detection of errors that otherwise would have been hidden or unknown.

Now, let us consider that this trend is real, but that it’s actually a bad thing. Multiple waves of COVID-19 in 2021 left many practices with significant numbers of staff out at one time for various reasons (e.g., personal, family illness, quarantine). This lack could have resulted in temporary deviations in the staffing policies of two radiation therapists per linac or fewer on-site physician or physics staff available to draw upon for guidance with a challenging setup. COVID-19 had a heightened impact on radiation therapists, as they were required to continuously support treatment delivery on site, while other professional roles may have been able to limit their public and workplace exposures for at least some portion of time. The compounded stress may have impacted performance, team relations and the work environment. This could result in COVID-19’s influence on safety being greater in the treatment delivery space than in the treatment planning space.

Now, let's consider interpretation 2: The number of events happening at treatment delivery is stable, but there are other confounding factors that skew the data.

In the United States, incident learning is voluntary, a crux of the legal protections afforded by the Patient Safety and Quality Improvement Act of 2005 and through participation in patient safety organizations (PSO). Estimates are that voluntary reporting only accounts for approximately 10% of the events that actually occur. Therefore, we must be careful when analyzing the data to ensure we appreciate this limitation. If PSO protections were not present, we would see even fewer of the events that occur, so it is essential that the anonymous, confidential work of the PSO remains supported.

One can imagine that the radiation oncology workforce is tired. With so many constraints on their time, in the second year of the pandemic, incident learning may have become a lower priority. RO-ILS recommends reporting any error that passes through the first checkpoint, regardless of whether it reaches the patient or is caught further downstream at a later safety check. However, we know not all practices are able to do this and that not all staff work in a culture of safety that supports this.

Although the number of events reported to RO-ILS has been fairly stable, the incident learning system has been functioning in an environment with staffing shortages, disrupted processes and individuals dealing with the mental task load of the pandemic. It is plausible that events occurring during treatment planning and on-treatment QA, which can be caught by normal QA, are deemed less of a priority to report than events happening at the linac. Therefore, with an underreporting of treatment planning and on-treatment QA occurring events, the relative percentage of events occurring at the linac would appear to rise.

In addition to practice-specific reporting thresholds, it is possible that changes in reporting patterns among RO-ILS enrolled practices have impacted the overall national trends. The extent to which some practices are reporting to the PSO cannot be ruled out as a cause of this trend.

What do you think? Which interpretation is more plausible to you? Importantly, are you seeing the same trends in your local practice’s incident learning data? As an individual practice, with knowledge of your practice-specific circumstances (e.g., staff, technology advancements, culture) the meaning of incident learning trends can be better postulated.

With support from the PSO, RO-HAC will dig deeper into the RO-ILS data to try to better understand possible contributing factors to this national trend. In the meantime, why do you think we are seeing this shift in the national data? Please comment below with your observations and thoughts.

Posted: April 12, 2022 | 0 comments