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Surveillance and evidence-based safety initiatives in radiation medicine.

247 Background: Moving towards safer radiation medicine requires an active surveillance of associated failures, their causes and effects, and evidence-based approaches for mitigation. In this study, by using retrospective and prospective surveillance, we have implemented evidence-based risk mitigation strategies in our radiation medicine practice.


METHODS
Incident learning has shown us that failures occur due to delays or defects in the radiation medicine process and that cultural error-provoking conditions raise these risks. Our initiatives were directed towards mitigation of defects in the high-risk process steps identified through a planning process FMEA. These included the standardization of care pathways and grading scale for assessing toxicity; pre-planning contour, directive peer review; electronic whiteboard for planning coordination and incident reporting, a process interlock policy to thwart delay-rushed processes; and the use of 6 sigma metrics to monitor individual staff operational efficiencies.


RESULTS
There has been a 3-fold increase over a 9 month period in incident reporting relative to the previous 6 previous years, by the peer group historically least likely to report, with no increase in adverse events. Evidence-based care pathways have been used with under 5% clinical non-compliance rates. The implementation of contour and directive pre-planning peer review has enhanced early defect detection. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Temporal trends demonstrate over 30% improvement in process Z-scores over the past three years.


CONCLUSIONS
Driving these risk mitigation initiatives has challenged traditional norms such as expediting treatment initiation in delay-rushed environments or sustaining care pathways that are more experience rather than evidence-based. Therefore their implementation has met with substantial barriers. It is the focus on patient safety, statistical process control, policy enforcement, regular incident reviews, and use of quantitative metrics that has been instrumental in realizing these changes and crossing barriers.