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"Medical error" and radiation

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https://www.readbyqxmd.com/read/29536927/medical-errors-malpractice-and-defensive-medicine-an-ill-fated-triad
#1
Leonard Berlin
For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission - i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission - i...
September 26, 2017: Diagnosis
https://www.readbyqxmd.com/read/29419944/incident-learning-in-radiation-oncology-a-review
#2
REVIEW
Eric C Ford, Suzanne B Evans
Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning...
May 2018: Medical Physics
https://www.readbyqxmd.com/read/28721904/treatment-planning-system-calculation-errors-are-present-in-most-imaging-and-radiation-oncology-core-houston-phantom-failures
#3
James R Kerns, Francesco Stingo, David S Followill, Rebecca M Howell, Adam Melancon, Stephen F Kry
PURPOSE: The anthropomorphic phantom program at the Houston branch of the Imaging and Radiation Oncology Core (IROC-Houston) is an end-to-end test that can be used to determine whether an institution can accurately model, calculate, and deliver an intensity modulated radiation therapy dose distribution. Currently, institutions that do not meet IROC-Houston's criteria have no specific information with which to identify and correct problems. In the present study, an independent recalculation system was developed to identify treatment planning system (TPS) calculation errors...
August 1, 2017: International Journal of Radiation Oncology, Biology, Physics
https://www.readbyqxmd.com/read/28586962/nature-of-medical-malpractice-claims-against-radiation-oncologists
#4
Deborah Marshall, Kathryn Tringale, Michael Connor, Rinaa Punglia, Abram Recht, Jona Hattangadi-Gluth
PURPOSE: To examine characteristics of medical malpractice claims involving radiation oncologists closed during a 10-year period. METHODS AND MATERIALS: Malpractice claims filed against radiation oncologists from 2003 to 2012 collected by a nationwide liability insurance trade association were analyzed. Outcomes included the nature of claims and indemnity payments, including associated presenting diagnoses, procedures, alleged medical errors, and injury severity...
May 1, 2017: International Journal of Radiation Oncology, Biology, Physics
https://www.readbyqxmd.com/read/28351153/gas-chromatography-mass-spectrometry-metabolomics-of-urine-and-serum-from-nonhuman-primates-exposed-to-ionizing-radiation-impacts-on-the-tricarboxylic-acid-cycle-and-protein-metabolism
#5
Evan L Pannkuk, Evagelia C Laiakis, Simon Authier, Karen Wong, Albert J Fornace
Ionizing radiation (IR) directly damages cells and tissues or indirectly damages them through reactive free radicals that may lead to longer term adverse sequelae such as cancers, persistent inflammation, or possible death. Potential exposures include nuclear reactor accidents, improper disposal of equipment containing radioactive materials or medical errors, and terrorist attacks. Metabolomics (comprehensive analysis of compounds <1 kDa) by mass spectrometry (MS) has been proposed as a tool for high-throughput biodosimetry and rapid assessment of exposed dose and triage needed...
May 5, 2017: Journal of Proteome Research
https://www.readbyqxmd.com/read/28134989/a-swiss-cheese-error-detection-method-for-real-time-epid-based-quality-assurance-and-error-prevention
#6
Michelle Passarge, Michael K Fix, Peter Manser, Marco F M Stampanoni, Jeffrey V Siebers
PURPOSE: To develop a robust and efficient process that detects relevant dose errors (dose errors of ≥5%) in external beam radiation therapy and directly indicates the origin of the error. The process is illustrated in the context of electronic portal imaging device (EPID)-based angle-resolved volumetric-modulated arc therapy (VMAT) quality assurance (QA), particularly as would be implemented in a real-time monitoring program. METHODS: A Swiss cheese error detection (SCED) method was created as a paradigm for a cine EPID-based during-treatment QA...
April 2017: Medical Physics
https://www.readbyqxmd.com/read/27979446/adverse-events-involving-radiation-oncology-medical-devices-comprehensive-analysis-of-us-food-and-drug-administration-data-1991-to-2015
#7
Michael J Connor, Deborah C Marshall, Vitali Moiseenko, Kevin Moore, Laura Cervino, Todd Atwood, Parag Sanghvi, Arno J Mundt, Todd Pawlicki, Abram Recht, Jona A Hattangadi-Gluth
PURPOSE: Radiation oncology relies on rapidly evolving technology and highly complex processes. The US Food and Drug Administration collects reports of adverse events related to medical devices. We sought to characterize all events involving radiation oncology devices (RODs) from the US Food and Drug Administration's postmarket surveillance Manufacturer and User Facility Device Experience (MAUDE) database, comparing these with non-radiation oncology devices. METHODS AND MATERIALS: MAUDE data on RODs from 1991 to 2015 were sorted into 4 product categories (external beam, brachytherapy, planning systems, and simulation systems) and 5 device problem categories (software, mechanical, electrical, user error, and dose delivery impact)...
January 1, 2017: International Journal of Radiation Oncology, Biology, Physics
https://www.readbyqxmd.com/read/27861907/factors-predictive-of-failure-to-complete-planned-intraoperative-breast-radiation-using-the-intrabeam%C3%A2-system
#8
Lesly A Dossett, Andrea M Abbott, Weihong Sun, Loretta Loftus, Marie Catherine Lee, Roberto Diaz, Christine Laronga
PURPOSE: Intraoperative radiation therapy (IORT) is a form of breast irradiation that is delivered in a single session at the time of partial mastectomy. In up to 10% of patients, planned IORT is not completed; this leads to wasted resources and decreased patient satisfaction. Our objective was to evaluate factors associated with failure to complete planned IORT. METHODS AND MATERIALS: An IRB-approved review of planned IORT cases from 2011 to 2015 was conducted...
December 2016: Journal of Surgical Oncology
https://www.readbyqxmd.com/read/27183943/medical-errors-and-patient-safety-in-the-operating-room
#9
Esra Ugur, Sevim Kara, Songul Yildirim, Elif Akbal
OBJECTIVE: To investigate medical errors in the operating room, attitudes of healthcare professionals in case of errors and educational needs of professionals. METHODS: The descriptive study was conducted at a university hospital in Turkey from January 25 to February 14, 2011, and comprised operating room staff, including physicians, nurses, anaesthesia technicians and perfusion technicians. Data was obtained using a questionnaire. RESULTS: Of the 69 respondents, 45(65...
May 2016: JPMA. the Journal of the Pakistan Medical Association
https://www.readbyqxmd.com/read/27026305/identifying-predictive-factors-for-incident-reports-in-patients-receiving-radiation-therapy
#10
Shereef M Elnahal, Amanda Blackford, Koren Smith, Annette N Souranis, Valerie Briner, Todd R McNutt, Theodore L DeWeese, Jean L Wright, Stephanie A Terezakis
PURPOSE: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. METHODS AND MATERIALS: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause...
April 1, 2016: International Journal of Radiation Oncology, Biology, Physics
https://www.readbyqxmd.com/read/26907449/analysis-of-after-hours-patient-telephone-calls-in-two-academic-radiation-oncology-departments-an-opportunity-for-improvement-in-patient-safety-and-quality-of-care
#11
Laura E G Warren, Miranda B Kim, Neil E Martin, Helen A Shih
PURPOSE: Patient care within radiation oncology extends beyond the clinic or treatment hours. The on-call radiation oncologist is often not a patient's primary radiation oncologist, introducing the possibility of communication breakdowns and medical errors. This study analyzed after-hours telephone calls to identify opportunities for improved patient safety and quality of care. METHODS AND MATERIALS: Patient calls received outside of business hours between July 1, 2013, and June 30, 2014, at two academic radiation oncology departments were retrospectively reviewed...
April 2016: Journal of Oncology Practice
https://www.readbyqxmd.com/read/26695903/medical-and-social-consequences-of-the-safety-problems-of-oncological-radiology
#12
M I Pylypenko, L L Stadnyk, M M Rygan, Ju M Skaleckyj, O Ju Shalopa
INTRODUCTION: Actuality of the problem of patient safety in oncoradiology in Ukraineis grounded. OBJECTIVE: assessment of the safety of patients who performed radiation therapy, and extent of medical and social consequences of erroneous actions of personnel in this area. MATERIAL AND METHODS: The results of international audit TLD (IAEA / WHO) quality during dosimetry procedures cobalt telehamma vehicles in Ukraine are investigated, as well as legal and regulatory framework providing for the safety of radiotherapy care, scientific publications on patient safety...
December 2015: Problemy Radiat︠s︡iĭnoï Medyt︠s︡yny Ta Radiobiolohiï
https://www.readbyqxmd.com/read/26577008/practical-implementation-of-quality-improvement-for-high-dose-rate-brachytherapy
#13
Leah Schubert, Arthur Liu, Gregory Gan, Arya Amini, Rebecca Hutchison, Janyce Ernest, Dale Thornton, Scott Stoehr, Bonnie Hinman, Kelly Stuhr, David Westerly, Tracey Schefter, Christine Fisher
PURPOSE: High-dose-rate (HDR) brachytherapy is a high-risk procedure with serious errors reported in the medical literature. Our goal was to develop a quality improvement framework for HDR brachytherapy using a multidisciplinary approach. This work describes the time, personnel, and materials involved in implementation as well as staff-reported safety benefits of quality improvement checklists. METHODS AND MATERIALS: Quality improvement was achieved using a department-wide multidisciplinary approach...
January 2016: Practical Radiation Oncology
https://www.readbyqxmd.com/read/26541132/implementing-an-electronic-event-reporting-system-in-a-radiation-oncology-department-the-effect-on-safety-culture-and-near-miss-prevention
#14
Rohan Deraniyagala, Chihray Liu, Kathryn Mittauer, Julie Greenwalt, Christopher G Morris, Anamaria R Yeung
PURPOSE: We implemented an electronic event-reporting system to investigate its effect on quality improvement in our department. METHODS: We developed an event-reporting program that launched in October 2012; data analysis was performed in January 2014. Events were logged by the radiation oncology staff and reviewed by our quality and safety committee on a biweekly basis. To measure the efficacy of the new program, and change in safety culture, a Likert-scale survey was administered before, and three months after, implementation of the event-reporting system...
November 2015: Journal of the American College of Radiology: JACR
https://www.readbyqxmd.com/read/26466177/root-cause-analysis-learning-from-adverse-safety-events
#15
Olga R Brook, Jonathan B Kruskal, Ronald L Eisenberg, David B Larson
Serious adverse events continue to occur in clinical practice, despite our best preventive efforts. It is essential that radiologists, both as individuals and as a part of organizations, learn from such events and make appropriate changes to decrease the likelihood that such events will recur. Root cause analysis (RCA) is a process to (a) identify factors that underlie variation in performance or that predispose an event toward undesired outcomes and (b) allow for development of effective strategies to decrease the likelihood of similar adverse events occurring in the future...
October 2015: Radiographics: a Review Publication of the Radiological Society of North America, Inc
https://www.readbyqxmd.com/read/26328985/a-quantification-of-the-effectiveness-of-epid-dosimetry-and-software-based-plan-verification-systems-in-detecting-incidents-in-radiotherapy
#16
Casey Bojechko, Mark Phillps, Alan Kalet, Eric C Ford
PURPOSE: Complex treatments in radiation therapy require robust verification in order to prevent errors that can adversely affect the patient. For this purpose, the authors estimate the effectiveness of detecting errors with a "defense in depth" system composed of electronic portal imaging device (EPID) based dosimetry and a software-based system composed of rules-based and Bayesian network verifications. METHODS: The authors analyzed incidents with a high potential severity score, scored as a 3 or 4 on a 4 point scale, recorded in an in-house voluntary incident reporting system, collected from February 2012 to August 2014...
September 2015: Medical Physics
https://www.readbyqxmd.com/read/26237049/unplanned-excision-of-extremity-soft-tissue-sarcoma-in-korea-a-nationwide-study-based-on-a-claims-registry
#17
Seungcheol Kang, Han-Soo Kim, Ilkyu Han
Unplanned excision of extremity soft tissue sarcoma (STS) is common and has detrimental effects not only on patients' oncologic outcomes but also on functional and economic issues. However, no study has analyzed a nationwide population-based database. To estimate the incidence and treatment pattern of unplanned excision in extremity STS in the Korean population, a nationwide epidemiologic study was performed using the Korean Health Insurance Review and Assessment Service database, a centralized nationwide healthcare claims registry of Korea that covers the entire Korean population...
2015: PloS One
https://www.readbyqxmd.com/read/26182183/improving-patient-safety-in-clinical-oncology-applying-lessons-from-normal-accident-theory
#18
Bhishamjit S Chera, Lukasz Mazur, Ian Buchanan, Hong Jin Kim, John Rockwell, Matthew I Milowsky, Lawrence B Marks
Concerns for patient safety persist in clinical oncology. Within several nonmedical areas (eg, aviation, nuclear power), concepts from Normal Accident Theory (NAT), a framework for analyzing failure potential within and between systems, have been successfully applied to better understand system performance and improve system safety. Clinical oncology practice is interprofessional and interdisciplinary, and our therapies often have narrow therapeutic windows. Thus, many of our processes are, in NAT terms, interactively complex and tightly coupled within and across systems and are therefore prone to unexpected behaviors that can result in substantial patient harm...
October 2015: JAMA Oncology
https://www.readbyqxmd.com/read/26178594/misadministration-of-radiation-therapy-in-veterinary-medicine-a-case-report-and-literature-review
#19
REVIEW
M M Arkans, T L Gieger, M W Nolan
Recent technical advancements in radiation therapy have allowed for improved targeting of tumours and sparing nearby normal tissues, while simultaneously decreasing the risk for medical errors by incorporating additional safety checks into electronic medical record keeping systems. The benefits of these new technologies, however, depends on their proper integration and use in the oncology clinic. Despite the advancement of technology for treatment delivery and medical record keeping, misadministration errors have a significant impact on patient care in veterinary oncology...
March 2017: Veterinary and Comparative Oncology
https://www.readbyqxmd.com/read/26144103/inadequacies-of-physical-examination-as-a-cause-of-medical-errors-and-adverse-events-a-collection-of-vignettes
#20
Abraham Verghese, Blake Charlton, Jerome P Kassirer, Meghan Ramsey, John P A Ioannidis
BACKGROUND: Oversights in the physical examination are a type of medical error not easily studied by chart review. They may be a major contributor to missed or delayed diagnosis, unnecessary exposure to contrast and radiation, incorrect treatment, and other adverse consequences. Our purpose was to collect vignettes of physical examination oversights and to capture the diversity of their characteristics and consequences. METHODS: A cross-sectional study using an 11-question qualitative survey for physicians was distributed electronically, with data collected from February to June of 2011...
December 2015: American Journal of Medicine
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