The American Association of Physicists in Medicine has published technical recommendations to help guide developers of databases that track and record treatment errors and near misses in radiation therapy.
The guidelines establish technical standards for incident learning specific to radiation oncology. Incident learning – the process of reporting an incident, analyzing it and developing safeguards to prevent it from happening again – plays a key role in improving the quality and safety of radiation therapy treatments.
In addition to outlining and defining common terminology for incident reporting, the recommendations address major topics like process mapping, severity metrics, causal taxonomies and data elements.
Process mapping involves defining the steps in the process of performing treatments and organizing them in a visual map. The report identifies 91 common steps for external-beam radiation therapy and 88 in brachytherapy. These steps include critical control points whose primary function is to prevent errors or mistakes from happening.
The report also includes:
- A 10-level medical severity scale that reflects estimated harm to a patient.
- A radiation oncology-specific root-causes table to facilitate and regularize root-cause analyses.
- Recommendations for data elements to aid in the development of electronic databases.
- A list of key functional requirements for any reporting system.
The Work Group on Prevention of Errors in Radiation Oncology developed the recommendations.
The workgroup included representatives from the AAPM, American Society of Radiologic Technologists, American College of Radiology, American Association of Medical Dosimetrists, American Society for Radiation Oncology, Canadian Organization of Medical Physicists, Conference of Radiation Control Program Directors, and U.S. National Institutes of Health.