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Open Access 05-08-2022 | Original Article

Risk management patterns in radiation oncology—results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project

Authors: Andrea Baehr, Daniel Hummel, Tobias Gauer, Michael Oertel, Christopher Kittel, Anastassia Löser, Manuel Todorovic, Cordula Petersen, Andreas Krüll, Markus Buchgeister

Published in: Strahlentherapie und Onkologie | Issue 4/2023

Abstract

Purpose

Risk management (RM) is a key component of patient safety in radiation oncology (RO). We investigated current approaches on RM in German RO within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project. Aim was not only to evaluate a status quo of RM purposes but furthermore to discover challenges for sustainable RM that should be addressed in future research and recommendations.

Methods

An online survey was conducted from June to August 2021, consisting of 18 items on prospective and reactive RM, protagonists of RM, and self-assessment concerning RM. The survey was designed using LimeSurvey and invitations were sent by e‑mail. Answers were requested once per institution.

Results

In all, 48 completed questionnaires from university hospitals, general and non-academic hospitals, and private practices were received and considered for evaluation. Prospective and reactive RM was commonly conducted within interprofessional teams; 88% of all institutions performed prospective risk analyses. Most institutions (71%) reported incidents or near-events using multiple reporting systems. Results were presented to the team in 71% for prospective analyses and 85% for analyses of incidents. Risk conferences take place in 46% of institutions. 42% nominated a manager/committee for RM. Knowledge concerning RM was mostly rated “satisfying” (44%). However, 65% of all institutions require more information about RM by professional societies.

Conclusion

Our results revealed heterogeneous patterns of RM in RO departments, although most departments adhered to common recommendations. Identified mismatches between recommendations and implementation of RM provide baseline data for future research and support definition of teaching content.

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Grau C, Borras JM, Malicki J et al (2013) Radiotherapy capacity in Europe. Lancet Oncol 14:e196–e198. https://doi.org/10.1016/S1470-2045(13)70069-XCrossRefPubMed

Shafiq J, Barton M, Noble D et al (2009) An international review of patient safety measures in radiotherapy practice. Radiother Oncol 92:15–21. https://doi.org/10.1016/j.radonc.2009.03.007CrossRefPubMed

World Health Organisation (2008) Radiotherapy risk profile Technical manual. WHO Press, World Health Organization, Geneva

Klüter S, Schrenk O, Renkamp CK et al (2021) A practical implementation of risk management for the clinical introduction of online adaptive Magnetic Resonance-guided radiotherapy. Phys Imaging Radiat Oncol 17:53–57. https://doi.org/10.1016/j.phro.2020.12.005CrossRefPubMedPubMedCentral

Rippke C, Schrenk O, Renkamp CK et al (2022) Quality assurance for on-table adaptive magnetic resonance guided radiation therapy: A software tool to complement secondary dose calculation and failure modes discovered in clinical routine. J Applied Clin Med Phys. https://doi.org/10.1002/acm2.13523CrossRef

American Society for Radiation Oncology (2019) Safety is no accident. https://www.astro.org/Patient-Care-and-Research/Patient-Safety/Safety-is-no-Accident/SINA-Digital-Book. Accessed 30 Oct 2020

Institute of Physics and Engineering in Medicine, National Patient Safety Agency, Society and College of Radiographers, Royal College of Radiologists (2008) Towards safer radiotherapy. British Institute of Radiology

European Commission (2015) Radiation protection No 181. General guidelines on risk management in external beam radiotherapy

Smith S, Wallis A, King O et al (2020) Quality management in radiation therapy: a 15 year review of incident reporting in two integrated cancer centres. Tech Innov Patient Support Radiat Oncol 14:15–20. https://doi.org/10.1016/j.tipsro.2020.02.001CrossRefPubMedPubMedCentral

10.

Patient Safety in Radiotherapy Steering Group, Public Health England, Centre for Radiation, Chemical and Environmental Hazards (2016) Radiotherapy errors and near misses data report (December 2013 to November 2015)

11.

Bundesamt für Strahlenschutz (2021) Melde- und Informationssystem für bedeutsame Vorkommnisse bei Strahlenanwendungen am Menschen. Jahresbericht 2020. Bericht der zentralen Stelle gemäß § 111 Abs. 1 Nr. 6 StrlSchV

12.

Schrappe M, Spahn J, Berwick DM, Durkin P (2018) APS-Weißbuch Patientensicherheit: Sicherheit in der Gesundheitsversorgung: neu denken, gezielt verbessern. Medizinisch Wissenschaftliche Verlagsgesellschaft, Berlin

13.

Adleman J, Gillan C, Caissie A et al (2017) Development of a quality and safety competency curriculum for radiation oncology residency: an international Delphi study. Int J Radiat Oncol Biol Phys 98:428–437. https://doi.org/10.1016/j.ijrobp.2016.11.031CrossRefPubMed

14.

Perneger T (2007) The Council of Europe recommendation Rec(2006)7 on management of patient safety and prevention of adverse events in health care. Int J Qual Health Care 20:305–307. https://doi.org/10.1093/intqhc/mzn034CrossRef

15.

Dunscombe P (2012) Recommendations for safer radiotherapy: what’s the message? Front Oncol. https://doi.org/10.3389/fonc.2012.00129CrossRefPubMedPubMedCentral

16.

Huq MS, Fraass BA, Dunscombe PB et al (2016) The report of Task Group 100 of the AAPM: application of risk analysis methods to radiation therapy quality management. Med Phys 43:4209. https://doi.org/10.1118/1.4947547CrossRefPubMedPubMedCentral

17.

(2015) Empfehlungen von BfS, DEGRO, DGMP und DGN zur Risikoanalyse bei therapeutischen Strahlenanwendungennach Artikel 63 Buchstabe b der EU-Direktive 2013/59/Euratom

18.

Buchgeister M, Hummel D (2021) Risikoanalyse in der Strahlentherapie: Muss es die FMEA-Methode mit RPZ sein? Z Med Phys 31:343–345. https://doi.org/10.1016/j.zemedi.2021.09.002CrossRefPubMed

19.

Ford EC, Evans SB (2018) Incident learning in radiation oncology: a review. Med Phys 45:e100–e119. https://doi.org/10.1002/mp.12800CrossRefPubMed

20.

Schubert L, Petit J, Vinogradskiy Y et al (2018) Implementation and operation of incident learning across a newly-created health system. J Appl Clin Med Phys 19:298–305. https://doi.org/10.1002/acm2.12447CrossRefPubMedPubMedCentral

21.

Ford EC, Fong de Los SL, Pawlicki T et al (2012) Consensus recommendations for incident learning database structures in radiation oncology: Incident learning structure. Med Phys 39:7272–7290. https://doi.org/10.1118/1.4764914CrossRefPubMed

22.

Marks LB, Rose CM, Hayman JA, Williams TR (2011) The need for physician leadership in creating a culture of safety. Int J Radiat Oncol 79:1287–1289. https://doi.org/10.1016/j.ijrobp.2010.12.004CrossRef

23.

Wright JL, Terezakis SA, Ford E (2021) Safety first: developing and deploying a system to promote safety and quality in your clinic. Pract Radiat Oncol 11:92–100. https://doi.org/10.1016/j.prro.2020.05.002CrossRefPubMed

24.

Belkacemi Y, Colson-Durand L, Fayolle-Campana M et al (2019) A wake-up call for routine morbidity and mortality review meeting procedures as part of a quality governance programs in radiation therapy departments: results of the PROUST survey. Pract Radiat Oncol 9:108–114. https://doi.org/10.1016/j.prro.2018.09.004CrossRefPubMed

25.

Albert JM, Das P (2013) Quality indicators in radiation oncology. Int J Radiat Oncol 85:904–911. https://doi.org/10.1016/j.ijrobp.2012.08.038CrossRef

26.

Lam MB, Figueroa JF, Feyman Y et al (2018) Association between patient outcomes and accreditation in US hospitals: observational study. BMJ 363:k4011. https://doi.org/10.1136/bmj.k4011CrossRefPubMedPubMedCentral

27.

Bundesgesetzblatt Jahrgang 2013 Teil I Nr. 9, ausgegeben zu Bonn (2013) Gesetz zur Verbesserung der Rechte von Patientinnen und Patienten vom 13.Februar 2013

28.

Bundesministerium der Justiz und für Verbraucherschutz (2018) 126 Risikoanalyse vor Strahlenbehandlungen. In: Verordnung zum Schutz vor der schädlichen Wirkung ionisierender Strahlung

29.

The council of the European Union (2013) Council directive 2013/59/EURATOM

30.

Malicki J, Bly R, Bulot M et al (2017) Patient safety in external beam radiotherapy, results of the ACCIRAD project: current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe. Radiother Oncol 123:29–36. https://doi.org/10.1016/j.radonc.2017.02.016CrossRefPubMed

31.

Pardo Masferrer J, Del Cerro Peñalver E, Contreras Martinez J et al (2020) Patient safety in radiation oncology in Spain: a need to change. Clin Transl Oncol 22:751–758. https://doi.org/10.1007/s12094-019-02184-xCrossRefPubMed

32.

Coffey MA (2017) Risk management, quality and safety in ESTRO. Tech Innov Patient Support Radiat Oncol 1:16–17. https://doi.org/10.1016/j.tipsro.2017.01.002CrossRefPubMedPubMedCentral

33.

DIRAC database IAEA Directory of radiotherapy centers (DIRAC). https://dirac.iaea.org/Query/Countries. Accessed 23.05.2022

34.

Baehr A, Oertel M, Kröger K et al (2020) Implementing a new scale for failure mode and effects analysis (FMEA) for risk analysis in a radiation oncology department. Strahlenther Onkol 196:1128–1134. https://doi.org/10.1007/s00066-020-01686-wCrossRefPubMed

35.

Yang F, Cao N, Young L et al (2015) Validating FMEA output against incident learning data: a study in stereotactic body radiation therapy. Med Phys 42:2777–2785. https://doi.org/10.1118/1.4919440CrossRefPubMed

36.

Ford EC, Smith K, Terezakis S et al (2014) A streamlined failure mode and effects analysis. Med Phys 41:61709. https://doi.org/10.1118/1.4875687CrossRefPubMed

37.

Ford EC, Gaudette R, Myers L et al (2009) Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. Int J Radiat Oncol Biol Phys 74:852–858. https://doi.org/10.1016/j.ijrobp.2008.10.038CrossRefPubMedPubMedCentral

38.

Medenwald D, Fietkau R, Klautke G et al (2021) Trends in radiotherapy inpatient admissions in Germany: a population-based study over a 10-year period. Strahlenther Onkol 197:865–875. https://doi.org/10.1007/s00066-021-01829-7CrossRefPubMedPubMedCentral

39.

Walsh KE, Dodd KS, Seetharaman K et al (2009) Medication errors among adults and children with cancer in the outpatient setting. J Clin Oncol 27:891–896. https://doi.org/10.1200/JCO.2008.18.6072CrossRefPubMed

40.

Vorwerk H, Zink K, Schiller R et al (2014) Protection of quality and innovation in radiation oncology: the prospective multicenter trial the German Society of Radiation Oncology (DEGRO-QUIRO study). Evaluation of time, attendance of medical staff, and resources during radiotherapy with IMRT. Strahlenther Onkol 190:433–443. https://doi.org/10.1007/s00066-014-0634-0CrossRefPubMed

41.

Lawrence YR, Whiton MA, Symon Z et al (2012) Quality assurance Peer review chart rounds in 2011: a survey of academic institutions in the United States. Int J Radiat Oncol 84:590–595. https://doi.org/10.1016/j.ijrobp.2012.01.029CrossRef

42.

Marks LB, Adams RD, Pawlicki T et al (2013) Enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: executive summary. Pract Radiat Oncol 3:149–156. https://doi.org/10.1016/j.prro.2012.11.010CrossRefPubMedPubMedCentral

43.

(2021) § 136a (3) Richtlinien des Gemeinsamen Bundesausschusses zur Qualitätssicherung in ausgewählten Bereichen. In: Fünftes Buch (V) Sozialgesetzbuch. Bundesministerin der Justiz und für Verbraucherschutz

44.

Brix G, Griebel J, Czarwinski R (2019) Melde- und Informationssystem für bedeutsame Vorkommnisse bei Strahlenanwendungen in der Medizin: Struktur, Zuständigkeiten und Meldekriterien. Z Med Phys 29:66–76. https://doi.org/10.1016/j.zemedi.2018.11.003CrossRefPubMed

45.

Petschnig W, Haslinger-Baumann E (2017) Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety. Saf Health 3:9. https://doi.org/10.1186/s40886-017-0060-yCrossRef

46.

Stavropoulou C, Doherty C, Tosey P (2015) How effective are incident-reporting systems for improving patient safety? A systematic literature review: incident-reporting systems for improving patients’ safety. Milbank Quarterly 93:826–866. https://doi.org/10.1111/1468-0009.12166CrossRefPubMedPubMedCentral

47.

Hewitt TA, Chreim S (2015) Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting: table 1. BMJ Qual Saf 24:303–310. https://doi.org/10.1136/bmjqs-2014-003279CrossRefPubMedPubMedCentral

48.

Hartmann J, Müller B, Singer J et al (2020) Vorkommnisse im Bereich der Röntgendiagnostik – Erfahrungen einer Multi-Center-Studie Leipzig (p s‑0040-1703348)

49.

Verstraete J, Isebaert S, Van den Heuvel F et al (2014) EP-1431: Implementing PRISMA-RT to analyze digitally reported (near) incidents and classify them for benchmarking. Radiother Oncol 111:S133. https://doi.org/10.1016/S0167-8140(15)31549-8CrossRef

50.

Spraker MB, Nyflot M, Hendrickson K et al (2017) A survey of residents’ experience with patient safety and quality improvement concepts in radiation oncology. Pract Radiat Oncol 7:e253–e259. https://doi.org/10.1016/j.prro.2016.11.008CrossRefPubMed

51.

Hoffmann B, Siebert H, Euteneier A (2015) Wie lernen wir, Patienten sicher zu versorgen? Patientensicherheit in der Ausbildung der Gesundheitsberufe. Bundesgesundheitsblatt 58:87–94. https://doi.org/10.1007/s00103-014-2075-4CrossRef

52.

Dietzel CT, Jablonska K, Niyazi M et al (2018) Quality of training in radiation oncology in Germany: where do we stand? : results from a 2016/2017 survey performed by the working group “young DEGRO” of the German society of radiation oncology (DEGRO). Strahlenther Onkol 194:293–302. https://doi.org/10.1007/s00066-017-1250-6CrossRefPubMed

53.

Büttner M, Cordes N, Gauer T et al (2021) Current status and developments of German curriculum-based residency training programmes in radiation oncology. Radiat Oncol 16:55. https://doi.org/10.1186/s13014-021-01785-7CrossRefPubMedPubMedCentral

54.

Weltgesundheitsorganisation (2018) Mustercurriculum Patientensicherheit, Multiprofessionelle Ausgabe, deutschsprachige Version. Charité - Universitätsmedizin Berlin, Berlin

55.

Manser T, Frings J, Heuser G, Mc Dermott F (2016) The German clinical risk management survey for hospitals: Implementation levels and areas for improvement in 2015. Z Evid Fortbild Qual Gesundhwes 114:28–38. https://doi.org/10.1016/j.zefq.2016.06.017CrossRefPubMed

56.

Rothmund M, Kohlmann T, Heidecke C‑D et al (2015) Einführung und Beurteilung von Maßnahmen zur Fehlerprävention in chirurgischen Kliniken: Ergebnisse einer aktuellen Online-Befragung. Z Evid Fortbild Qual Gesundhwes 109:384–393. https://doi.org/10.1016/j.zefq.2015.06.010CrossRefPubMed

Title: Risk management patterns in radiation oncology—results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project
Authors: Andrea Baehr
Daniel Hummel
Tobias Gauer
Michael Oertel
Christopher Kittel
Anastassia Löser
Manuel Todorovic
Cordula Petersen
Andreas Krüll
Markus Buchgeister
Publication date: 05-08-2022
Publisher: Springer Berlin Heidelberg
Published in: Strahlentherapie und Onkologie / Issue 4/2023
Print ISSN: 0179-7158
Electronic ISSN: 1439-099X
DOI: https://doi.org/10.1007/s00066-022-01984-5

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Risk management patterns in radiation oncology—results of a national survey within the framework of the Patient Safety in German Radiation Oncology (PaSaGeRO) project

Abstract

Purpose

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusion

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