QA Project #4 Deviation Review/Policy Creation

QA Project #4Deviation Review/Policy CreationKatie DeMeulemeester

CaseSL306/03/11Time: Diagnosis: Left Mycosis Fungoides, unspecified sitePrimary site: left gluteal areaGoal of treatment: curative Beam energy/modality: e08Ports: 313Dose: Total: 3600 cGy Daily: 180 cGy x 20 fractionsFraction #: 13 of 17

HistoryFemale 10/20/1942A 68-year-old Caucasian female with a known diagnosis of a stage IV a refractory cutaneous T-cell lymphoma. She has undergone a series of systemic therapies as above noted and well summarized in previous notations made by Dr. Mark Kaminski as well as Dr. Jaiyesimi, which are attached to this chart/consultation. Most recent treatment has been with Campath systemic therapy under the guidance of Dr. Jaiyesimi. The response has been quite good except for a persistent lesion within the left buttock region, with a maximum dimension of 2.5 cm. She has had prior scalp irradiation delivered at the University of Michigan under the guidance of Dr. Christine Tsien, which resulted in a quite durable response within the scalp which was irradiated. Thus, based on this excellent prior response to the cutaneous lesions involving her scalp, I believe a course of local field irradiation to the persistent left buttock lesion should respond equally well. Pursuant to this, I have contacted our scheduling office to arrange for a simulation treatment planning session. I believe that the modality of choice would be a direct en-face electron field with relatively low energy, i.e., 6 or 8 MeV to a similar total dose as per previous scalp treatment, i.e., 24 to 25 Gy.

PAST MEDICAL HISTORY: She denies any major medical problems other than for that reported in the History of Present Illness. Indeed, she denies any hypertension, diabetes mellitus, or other chronic medical conditions. She did have a deep venous thrombosis in the year 2001.

FAMILY HISTORY: Father with colonic cancer; a paternal grandmother with gastric cancer, a sister with breast cancer; a great aunt with stomach/gastric cancer, a great-cousin with brain tumor.

DeviationLeft buttocks electron field was treated with the wrong electron blockPlanned block dimensions: 8.5 cm wide x 7 cm longTreated with a block of dimensions: 8.5 cm wide x 9 cm long, a breast patients block

Explanation The electron block was left in the cone from the previous patients treatmentThe block was not checked before treatmentThe machine may have been behind and in a hurry when clearing the table of the set up before this patient, leaving the block in the cone, then in a hurry when setting up for this patient and did not stop to check to make sure it was the correct block

Discovery of deviation The deviation was discovered after the patient was treated and the therapist was taking the block out of the electron cone

Dose deviation at c/aAccording to the dosimetrist there is no compensation Because the treatment is with electrons and the blocks were so close in size Electrons are treated to a depth, so even with the wrong block the patient still got there prescribed dose, but received extra dose to the surrounding skin in the 2 cm If a small block was used instead of a big block, scatter would affect the dose received

Consequences to patientSince the deviation was something that will most likely not happen again to the same patient, there are no consequencesIf it did some how continue, the area that the doctor wanted treated could be missed or cut off by the block, the patient would not get the same results, or possibly no results to the area

Current practicesCurrently the practice of making sure the correct block is in for the correct patient is to check and double check which block is in the electron cone

Documentation MEDTEC Note: Field 1A treated with cast block measuring 8.5 cm x 9 cm in dimension. Dr. Chen notified, no change to treatment plan needed. DRKA brief note should be put in about what happened, then a deviation report should be filled out with all of the details

Recommendations Always remove blocks from electron cone immediately after treatmentDo not keep multiple blocks out at the same timeCheck the name on block when setting up the table, again when setting up the patient and again before leaving the roomIf someone else setup for the patient check the block for yourselfBring up the image of the electron block for each setup, to double check your position and make sure it is the correct shape and block

Future advancesA barcode system could help with treating with the wrong blockEach electron block could have a barcode which is scanned before placing it inside the cone, you would not be able to treat if the block is not scanned or it is not the correct block

Policy When setting up the room get the cone ready and plane the patients block next to it, not inside the coneAfter leveling the patient attach the cone then check the name on the block and place it in the coneHave each therapist that is setting up check the name on the electron blockBring up the image of the block on the computer screen to verify the shape and position of the block, this could get rid of uses of the wrong block by noticing it does not look like the pictureBefore leaving the room after setup is complete recheck the block