Bowtie Analysis To Enhance Patient Safety In Radiation Oncology

The majority of radiation treatments (RT) are delivered safely and as intended. Nevertheless, events still occur, and additional strategies might be helpful in assuring safety. We herein apply Bowtie Analysis (BTA) (a novel barrier management system often used in industry) to RT to better understand our systems and associated safety events. We performed BTA in our RT department including: 1) creation of a generic process map or “care path” of the steps within our RT delivery process; 2) selection of a major hazard (or “top event”) within RT that we strive to prevent; 3) identification of threats (human errors likely to lead to the top event if not prevented) that occurred that could have led to the top event; 4) identification and evaluation of the controls in place within our department to prevent these threats; and 5) classification of the controls as barriers, key safeguards, or safeguards based on their robustness and effectiveness. This framework was used to assess a series of safety-related incidents in our clinic related to one selected, relatively common, challenge in our clinic. Final care path included 160 steps. Twelve incidents (involving 0.3% of patients) occurring during a defined time related to patient site setup notes, that could have led to site setup errors (“top event”), were analyzed in depth. Human errors contributing to these incidents were then labeled as threats to site setup fidelity. Five incidents were related to the threat of conflicting bladder information (bladder full vs. empty), 3 related to iso-center shift differences between documentation in the site setup note compared to elsewhere, 3 related to missing a site setup note entirely, and 1 related to the site setup note not followed at patient setup. Table presents a representative example of controls and their type including their effectiveness to prevent these threats. BTA provided valuable insight into the identity and efficiency of the controls within our department to protect against errors related to a representative “top event” (e.g. site setup errors). This analysis has helped us realize that we need to improve the robustness and effectiveness of many of our controls and strategically implement audits into our QA management program to help ensure patient safety.Abstract 3434; Table 1Representative event (conflicting bladder guidance): analysis of controls for threatsControlTypeOwnershipTraceabilityAuditableSpecificIndependentEffectiveTo Minimize Treatment ErrorsRecords Present for Inspection (None were audited regularly)Specific Person, Task, & Goal PresentIndependent of other Controls for ThreatDOS Complete Pre-Treatment Check via ChecklistAll SafeguardsüüüüüX0% (0/5)PHY completes Pre-Treatment Check via ChecklistüüüüüX20% (1/5)CT-Sim RTT Completes Chart Write-UpüüüüüX0% (0/4)MD Reviews & Approves Setup Image, Orders Shifts if NeededüüüüüX0% (0/4)MD Daily/Weekly Image ReviewüüüüXX0% (0/4)PHY Completes Weekly Chart Checküüüüüü100% (4/4) Open table in a new tab