RO-ILS Case Study 01

Error in Scheduling Patient Treatment 

Event Summary:

• Treatment to two different sites with different fractionation schemes resulting in different end dates. 
• The site with the least treatments, the C-spine, did not receive treatment on one treatment day due to the record and verify software crashing.
• The therapist informed the physician the C-spine was not treated that particular day.
• The physician talked with the physicist, who told the therapists it was okay for the treatment calendar to reflect an under dose on that date, as this indicated what actually happened and was approved by the physician. 
• However the patient was incorrectly scheduled such that both sites had the same end date; meaning one of the sites was scheduled to receive one too many fractions.
• The record and verify system gave an alert to the therapists indicating they were about to exceed the prescription dose for that site.
• One therapist wanted to ignore the warning and override it, thinking it was a result of the previously untreated field, but the other therapist was uncomfortable and called physics to be sure.
• Physics recognized that the patient was about to be treated beyond the prescription and stopped treatment for this site.

Lessons Learned:

When treating more than one course or site at the same time, extra caution is needed to promote delivery of safe treatment. During the pre-treatment chart QA it is vital to confirm the number of scheduled patient appointments, fractions scheduled in the treatment calendar, and the prescription. There is also a human-factors engineering aspect to this case in that the software was designed to warn the therapists just prior to treatment that an overdose was about to occur. Could the software be designed such that it is not possible to schedule such an overdose in the first place or at least warn the user earlier? This case demonstrates an example which is clearly not the "fault" of the therapist but rather an outcome of them working in an imperfect system. When things do go wrong, like in this case, it is important to have the therapists working as a team to make sure a check and balance system is in place. Additionally, staff should be educated and trained to not be impulsive when reading vendor warnings and alerts. While certain situations in healthcare may cause a person to react instinctively, many tasks require staff to stop and consider the consequences of their actions and be empowered to stop the process when needed. Asking, for example, Did I read the alert that popped up on the screen? What will be the outcome if I ignore this alert?

Suggestions and Actions:

Due to the increasing demands and complexity of healthcare, hard stops are put into place to avoid breakdowns in the system. Policies and procedures requiring that staff check certain criteria, such as scheduling information, during the pre-treatment chart QA and weekly chart checks can help catch similar errors. Additionally, having a clear area of the medical record where notes are written and where all staff know to look can assist in avoiding errors. Writing notes in this comment section on the schedule to explicitly state when one site will be completed can be a helpful reminder to clinical and administrative staff. This is all part of managing the patient’s medical record daily in the event they do miss a day. Documenting in the electronic medical record that the treatment calendar and patient schedule were adjusted, is an excellent communication tool to notify other staff of the change. It is recommended that a minimum of at least two qualified therapists be present for any external beam radiation therapy treatment. Additionally, all questions and concerns need to be addressed prior to commencing treatment. Because of safety culture and teamwork, the event was caught before it reached the patient. Encouraging staff to keep the lines of communication open will promote an environment where people are willingly to raise concerns and engage in peer coaching if needed. To promote open lines of communication amongst staff and support a safety culture, facilities should focus on the need to tighten practice patterns, improve quality of care and patient safety, not on blaming an individual. Finally, vendors need to be encouraged to produce software that minimizes or eliminates errors like this.

Additional Reading:

Patient Safety: Dekker. Sidney. (2011). A Human Factor Approach. Boca Raton: CRC Press by Taylor and Francis Group, LLC.