Improving the quality of care during radiation therapy planning and delivery
Radiation therapy is the process of applying carefully calculated doses of radiation directly to tumors or areas with cancer cells to prevent their growth. Recently, there has been media attention to unsafe radiation therapy in some healthcare centers and resulting harm to patients. Some of our patients have been asking what we do at Northwestern Memorial Hospital to ensure that the radiation therapy they are receiving is as safe and effective as possible.
At Northwestern Memorial, we have always recognized that there are risks involved with radiation, and because of those risks, patient safety is and always has been our number one priority. Radiation therapy can be provided safely with proper systems and precautions. Most radiation therapy errors are associated with a lack of quality assurance processes. We believe in creating an environment to allow for the safest possible processes and safety checks.
Steps we take to ensure patient safety
With the goal of zero preventable errors, we have created a three-part, comprehensive approach to quality and safety of radiation treatment. Following is an outline of the steps we take to ensure patient safety:
Equipment Quality Assurance
- We perform daily, monthly and annual physics calibration and output checks of all radiation equipment
- We gather outside confirmation of radiation levels via a government sponsored institution, the Radiological Physics Center, and clinical trial cooperatives
Patient-Specific Quality Assurance
- We perform primary and secondary calculations to verify the accuracy of the radiation dose
- Medical physicists (specially trained staff with a M.S. and PhD in radiation physics) supervise and approve calculations for all treatment plans
- We perform quality assurance checks of Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS and SBRT) plans prior to treatment
- Therapist staff reviews plans to verify agreement between the radiation dose in the treatment plan and the treatment machine
- Prior to therapy, we perform a “time-out,” something like a pre-flight checklist on an airplane, to verify the physician's written order, the prescribed dose programmed into the machine, and the patient's identity
Personnel-Specific Quality Assurance
- We conduct audits to ensure that staffing and time-out verifications are appropriate
- First Treatment Timeout Audits
- Daily Treatment Timeout Audits
- We always staff a minimum of two therapists per treatment unit
In addition, we:
- Follow published guidelines from the American Association of Physicists in Medicine about the performance testing of all radiation therapy technology
- Comply with regulatory requirements
- Engage in a radiation oncology peer-review program that includes a focus on quality assurance
How we developed our safety and quality process
Our process was developed over a period of years after much research and discussion, and we believe it’s both effective and unique. Since we put the process into place, it has proven its benefit in catching near-miss events and confirming accuracy of treatments.
Radiation therapy is considered a high risk procedure because it is a complex process, involving many steps and several disciplines and because it is a potentially harmful treatment if applied incorrectly. When patients go through the process of radiation therapy, their care is provided by a number of staff members, including:
- Radiation Oncologists
- Radiation Physicists
- Medical Dosimetrists
- Radiation Therapists
- Oncology Nurses
- Social Workers
- Engineers and Informational Technologists
- Administrative Support Personnel
When this many people are involved in providing healthcare, accurate communication is essential.
Another reason that radiation therapy can be risky is that it requires great precision. The smallest calculation error can have huge implications in the delivery of care. Errors in radiation therapy are not common, but they do occur, as highlighted in recent media articles about various hospitals’ experience of radiation errors.
What Northwestern Memorial is Doing to Reduce the Risk
To help prevent future errors, Northwestern Memorial performed a prospective analysis to thoroughly examine our process in order to identify specific causes or factors that could contribute to potential errors at our hospital and others. We analyzed our entire process – from the time patients came in for a consultation until their treatment was completed -- and we identified parts of the process that could be improved.
We combined what we learned through our analysis with recommendations based on The Joint Commission’s Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person SurgeryTM to assure safe and reliable radiation therapy procedures. We identified four important steps of the process that now aid us in reducing the potential for error. They are:
- A detailed pre-simulation order must be completed and approved by the Radiation Oncologist
- A post-treatment planning “timeout” must occur between the planner and the Radiation Oncologist ensuring review of all parameters (a timeout is a formal step in the process involving the patient and the care team, with a checklist that must be followed to make sure all steps are done in order)
- A pre-initial treatment timeout must occur between Radiation Therapists and the Radiation Oncologist for any new treatment
- A daily pre-treatment delivery timeout must occur between at least two Radiation Therapists to identify correct patient and treatment parameters
Each of these steps is accompanied by a checklist to aid in consistency, quality and efficiency of the timeout. Documentation of the timeouts is done online in our Electronic Medical Record (EMR), which is recorded in the patient’s chart. This allows for real-time auditing of the process, and it assures staff will complete it reliably.
The use of the four checklists has significantly changed the way in which we plan and deliver radiation therapy. Using a standardized routine and pre-procedure process of verifying the patient and the correct site with the patient and sharing accountability among the healthcare team assures us that our system is reliable and safe.
We have found that adhering to the checklists helps in many ways. It:
- Improves communication among the healthcare team by fostering collaboration and cooperation
- Involves the patient in active participation in the pre-procedural process
- Forces busy healthcare workers to slow down and pause for critical verification prior to starting the radiation procedure
The use of checklists breaks down complex tasks to their component parts and ensures that nothing left out.
Increased Patient Satisfaction
Patient satisfaction is an important part of our goal to deliver exceptional care to every patient every time. Since we implemented our checklists and timeouts, our patient satisfaction scores have increased to 98.4 percent, which is the highest patient satisfaction score in the hospital.
If you have questions about the safety of radiation therapy or the process we use to ensure your safety, please click the feedback button on the right side of the screen.