Table 3.

Factors contributing toward either preventive (good catches/near misses) or reactive findings as reported and analyzed based on our incident-reporting and analysis system.

Safety events: preventive and reactive
DISCREPANCY IN EMR (33%)
Dose tracking per field inconsistent with Rx, field, or DRR name mismatch, incorrect DRRs, field parameter mismatch (gantry, collimator, couch angles, fields swapped, monitor units), prescription mismatch, accessory mismatch, incorrect field size, incorrect beam energy, incorrect treatment time set-up in fields, documents for a different patient, treatment plan issues (bolus, dose computation inconsistent with prescription, images not fused, incorrect accessory factor, MLC settings, overlap with previously treated fields, plan inconsistent with directive, treatment plan for different linear accelerator plan inconsistent with simulation set-up notes), field parameters changed inadvertently on first day physics check, field size changes following system upgrade
MISSING TREATMENT APPROVALS IN EMR (15%)
Physician approvals (prescription, treatment plan, pathology review documentation), physics approvals (IMRT QA documentation, treatment fields, second check approval of treatment plan, planner approval of treatment plan), multiple approvals missing, second physics check approval completed prior to field parameter entry completion, incomplete quality checklist tasks
PATIENT SET-UP (12%)
Port film issues, machine clearance issues, insufficient field coverage, difficulties with treatment aids/devices, incorrect treatment device fabrication, missing devices, Vac-loc bag deflation, incorrect localization methodology, set-up difficulties due to changes in patient anatomy or preparation, patients could not tolerate set-up
ON-TREATMENT CHECKS DELAYED/MISSING/INCORRECT (11%)
Patient in vivo (nanodot) measurements not documented in EMR, first day physics check delayed, not documented or documented prior to first day treatment, weekly physics chart check note missing, quality checklists (e.g., laterality) not completed
VARIANCE (INCORRECT DOSE DELIVERED, INCORRECT VOLUME IRRADIATED OR BOTH) (11%)
Incorrect treatment field used (handoff), not all treatment fields delivered (fields hidden), incorrect shifts applied (handoff), bolus not used, incorrect gantry angle used (override, wide tolerance tables, communication between EMR and Linac communications), incorrect fractionation delivered (treatment calendar), incorrect block used (text overlay on DRR), incorrect monitor units (incorrect use of MU calculation sheet, missing physics check, tray factor), incorrect collimator angles, partial treatment delivered (machine limitations, EMR and Linac communications), incorrect energy used, incorrect couch angle, incorrect accessory used, incorrect field size (inadvertent asymmetric to symmetric setting change on first day physics check), IGRT localization data for different patient used, incorrect fiducial markers used, pacemaker patient received one treatment without rhythm strip, patient simulated without physician documentation in EMR, incorrect SSD (override), field block by couch top
MISSING/INCORRECT DOCUMENTS IN EMR (8%)
Pathology report missing prior to V-SIM, pacemaker alert and/or dosimetry information missing, IMRT QA report missing, treatment plan missing, insurance authorization documents missing, patient identification documents missing, consultation documents missing, second physics check document missing
PATIENT INCIDENT (7%)
Fall/slippage/collision, rapid response or emergency procedures unrelated to radiation therapy (breathing, O2 saturation drop, blood pressure), injury (procedural complications – applicator insertion or removal, removal of ekg lead, removal of HDR unit prior to removing catheter), coordination-of-care (pre-operative radiation delivered for subsequently delayed surgery)
STAFF INCIDENT (3%)
Fall/slippage/collision; injury while assisting patient, exposure to bodily fluids or matter, electrical shock (field engineer)