Or

Quality and safety must be prioritieswithin Radiation Oncology. within

and safety must be priorities within Radiation Oncology.

ation Oncology.•

PAST Current Future

KL2014 2

To Err Is Human

14 years

Since report “To Err Is Human”

(Kohn, Corrigan, and Donaldson 2000)

KL2014 3

Are we improving?

Operations on the wrong patient or the wrongbody part continue to take place, perhaps as often

as 50 times per weekin the United States

(estimated from: Minnesota Department of Health2013).

KL2014 4

What Type of Organization Leads to a Safety Culture

• http://you http://youtu.be/8NPzLBSBzPItu.be/8NPzLBSBzPI

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Safety Culture

“…the attitudes, beliefs, perceptions and values that employees share in

relation to safety…”

Cox, S. & Cox, T. (1991) The structure of employee attitudes to safety ‐ a European example Work and Stress, 5, 93 ‐ 106.

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Organization

Positive Safety Culture Characteristics

• Mutual trust • Shared perceptions of the importance of

safety • Confidence in efficacy of preventive

measuresHSC (Health And Safety Commission), 1993. Third report: organizing for safety. ACSNI Study Group on Human Factors. HMSO, London.

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Past

There was fear of reporting incidents…

WHY?

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Beginning of Time - 1980’s

• Few incidents were reported• Technology was simple-few computers• Cobalt, Ortho and Single Energy Accelerators• AP/PA• Hand Placed Blocks• Hand Calcs -Few computer• Near Misses were rarely thought about• No record and verify systems

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Beginning of Time - 1980’s

• Wrong field size• Wrong time set• Wrong distance• Wrong blocks• Wrong decay factor• Source may get stuck• Bad skin reactions

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Event Log of 1990

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Would Record and Verify Help?

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2005 Variance Report Form

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Current

•Leadership

•Safety Culture

•Robust reporting system

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Are we getting better?Are we having same problems nationally?

1990

Wrong Field sizeWrong MUWrong EnergySSDDot Grad InWrong BlockWrong plan usedWrong Calculation of MUWrong immobilizationNo bolus

20021980

Wrong field sizeWrong time setWrong distanceForgot blocksWrong decay factorSource may get stuck

2014

Wrong siteReference points drawn wrongBolus left outNo breath holdNear misses with system errorsWrong iso

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Variance Workgroups

Purpose:

1.Review all variance’s 2. Identify priority 3. Conduct root cause analyses 4. Recommend changes to process 5. Look for common causes and trends

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Membership of Variance Workgroups

Include Members From all Areas

• Scheduling• Simulation• Dosimetry/Physics• RTT• Faculty and Administration

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Safety Organization

Radiation Treatment Delivery is Complex:

• Standard QA – Common Errors• Errors such as machine dose• Misalignments of the patient• Scheduling is complex• Many handoffs• What errors are not being caughtJt Comm J Qual Patient Saf. Jul 2011; 37(7): 291–299. 

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Incident Detailed Review

“Errors, whether reaching the patient or a workflowissue not reaching the patient, are often

multifactorial and require a detailed review in order to avert or at least minimize future errors…”

Workflow Enhancement (WE) Improves Safety inRadiation Oncology: Putting the WE and Team

TogetherSamuel T. Chao, MD,*,y

Tim Meier, RTT,* Brian Hugebeck, RTT,*Chandana A. Reddy, MS,* Andrew Godley, PhD,* Matt Kolar, MS,*

and John H. Suh, MD*,*Department of Radiation Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio; and

Rose Ella Burkhardt Brain Tumor and Neuro-oncology Center, Cleveland Clinic, Cleveland, Ohio

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High-Reliability Organizations (HROs)

“Collective Mindfulness”

(Weick and Sutcliffe 2007).

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What is Reliability?

“Reliability depends on the lack of unwanted, unanticipated, and unexplainable

variance in performance…”

• -Eric Hollnagel, 1993, p. 51

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High Reliability Systems

1. Preoccupation with failure2. Reluctance to simplify interpretations3. Sensitivity to operations4. Cultivation of resilience5. Willingness to organize around expertise

Karl E. Weick & Kathleen M. Sutcliffe, “Managing the Unexpected,”Jossey‐Bass, 2001 

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Future Organizations

• Hire Problem solvers• Spend time training staff• Understand that a safe culture will report 4-

5 variances per week• Decide should we focus on problem

variances or near misses?• Include patients with our safety initiatives

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Brainstorming for the FUTURE

• Hiring a Safety Officer or a lead to storm and investigate

• Continue to report and review utilizing all Systems

• Review National Data-RO-ILS

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Air Travel, Nuclear Power, Amusement Parks

Air Travel, Nuclear Power, Amusement Parks…

Have become“high reliability”

(Reason 1997; Weick and Sutcliffe 2007).

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Organization

A well-designed organization is not a stable solution to achieve, but a developmental process to keep active.

(Starbuck & Nystrom, 1981, p. 14)

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In the US, operations on the wrong patient or the wrong body part take place as often as…

20%

20%

20%

20%

20% 1. 50 times per year2. 50 times per week3. 20 times a day4. 150 times a week

10

KL2014 27

In the US, Operations on the wrong patient or the wrong body part take place as often

20%

20%

20%

20%

20% 2. 50 times per week1. Enter answer text here...2. Enter answer text here...3. Enter answer text here...4. Enter answer text here...

10

(estimated from: Minnesota Department of Health 2013).

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Which of the following is not a Positive Safety Culture Characteristic

20%

20%

20%

20%

20%1. Mutual Trust2. Confidence in efficacy of preventive

measures3. Punitive action4. Shared perceptions of the importance of

safety

10

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Which of the following is not a Positive Safety Culture Characteristic

20%

20%

20%

20%

20% 3. Punitive action1. Enter answer text here...2. Enter answer text here...3. Enter answer text here...4. Enter answer text here...

10

HSC (Health And Safety Commission), 1993. Third report: organizing for safety. ACSNI Study Group on Human Factors. HMSO, London.

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High Reliability Systems…

20%

20%

20%

20%

20% 1. Are less sensitive to operations 2. Lack cultivation of resilience3. Are not willing to organize around expertise 4. Are pre-occupied with Failure5. Enter answer text here...

10

KL2014 31

High Reliability Systems

20%

20%

20%

20%

20% 4. Are Pre-occupied with Failure1. Enter answer text here...2. Enter answer text here...3. Enter answer text here...4. Enter answer text here...

10

Karl E. Weick & Kathleen M. Sutcliffe, “Managing the Unexpected,”Jossey‐Bass, 2001