The reduction of radiation therapy error project: assisting the development and implementation of a national radiotherapy incident reporting system

Awardee: Graham Smith

Graduate Program: PhD

Institution: Queen’s University

Supervisor(s): Michael Brundage

ARCC Program Area(s):

Competition: 2016

Project Summary:

Although radiation treatment of cancer patients (ie. radiotherapy) has become safer over time due to advancements in treatment techniques and medical technology, clinician errors in the delivery of treatment to patients still occur on a regular basis.  An incident in radiotherapy results when a safeguard in the treatment delivery process fails to catch a clinician error allowing the error to potentially, or actually effect a patient’s treatment outcome.  Although severe incidents in radiotherapy are rare, minor incidents as well as incidents that are caught prior to impacting a patient (ie. potential incidents) are quite common.  Incident data provides radiotherapy quality assurance programs at cancer centres with the ability to identify areas for patient safety improvement, such as pinpointing deficiencies within the safeguards of the radiation treatment delivery process that require remediation.  Providing safe radiation treatment to patients is an integral part of ensuring quality radiotherapy is delivered to all Canadian cancer patients.

To date, no national radiotherapy incident reporting database exists that combines incident data from all Canadian cancer centres.  The Canadian Partnership for Quality Radiotherapy (CPQR), which is a collaborative organization comprised of radiotherapy clinicians and researchers across Canada, has launched an initiative to develop and implement a national radiotherapy incident database.  Having a national radiotherapy incident database will provide researchers with important data that can be used to monitor incidents and identify targets for safety improvement on a national scale.  A database containing radiotherapy incident data from all Canadian cancer centres also provides a venue for information sharing and a learning opportunity for all Canadian cancer institutions.

This project will aid the CPQR develop and implement a national radiotherapy incident reporting database.  The project will collect and statistically analyze radiotherapy incident data from four Canadian cancer centres.  This project will attempt to identify safeguards with poor performance within the radiotherapy delivery process with the aim of identifying targets for safety improvement.  Results from this study will be used to help improve safety of radiotherapy at Canadian cancer centres.