Implementation of a No Fly safety culture in a multicenter radiation medicine department

Practical Radiation Oncology

Volumn 2, Issue 1, 2012, Pages 18-26

  Potters, Louis ^a   Kapur, Ajay ^a  

^a Northwell Health   (United States)

Author keywords

[No Author keywords available]

Indexed keywords

ARTICLE; CHECKLIST; CONSULTATION; DISEASE COURSE; ELECTRONIC MEDICAL RECORD; EXTERNAL BEAM RADIOTHERAPY; HEALTH CARE DELIVERY; HEALTH CARE POLICY; HEALTH CARE QUALITY; HOSPITAL DEPARTMENT; HOSPITAL INFORMATION SYSTEM; HUMAN; INTENSITY MODULATED RADIATION THERAPY; MAJOR CLINICAL STUDY; MEDICAL PRACTICE; PATIENT SAFETY; PILOT STUDY; PRIORITY JOURNAL; PROCESS CONTROL; QUALITY CONTROL; RADIOTHERAPY; RISK ASSESSMENT; RISK REDUCTION; ROOT CAUSE ANALYSIS; TREATMENT PLANNING;

EID: 84155168967     PISSN: 18798500     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.prro.2011.04.010     Document Type: Article

References (50)

1. Fraass BA, Lash KL, Matrone GM, et al. The impact of treatment complexity and computer-control delivery technology on treatment delivery errors. Int J Radiat Oncol Biol Phys 1998, 42:651-659.
2. Huang G, Medlam G, Lee J, et al. Error in the delivery of radiation therapy: results of a quality assurance review. Int J Radiat Oncol Biol Phys 2005, 61:1590-1595.
3. Marks LB, Light KL, Hubbs JL, et al. The impact of advanced technologies on treatment deviations in radiation treatment delivery. Int J Radiat Oncol Biol Phys 2007, 69:1579-1586.
4. Amols HI New technologies in radiation therapy: ensuring patient safety, radiation safety and regulatory issues in radiation oncology. Health Phys 2008, 95:658-665.
5. Williamson JF, Thomadsen BR Foreword. Symposium quality assurance of radiation therapy: the challenges of advanced technologies. Int J Radiat Oncol Biol Phys 2008, 71(Suppl 1):S1.
6. Siochi RA, Balter P, Bloch CD, et al. Information technology resource management in radiation oncology. J Appl Clin Med Phys 2009, 10:3116.
7. Donaldson SR Towards safer radiotherapy. The Royal College of Radiologists, Society and College of Radiographers, Institute of Physics and Engineering in Medicine, Patient Safety Agency, British Institute of Radiology 2008, Available at https://www.rcr.ac.uk/docs/oncology/pdf/Towards_saferRT_final.pdf. Accessed March 31, 2011.
8. Radiotherapy risk profile 2008, World Health Organization, Geneva, Switzerland, Available at http://www.who.int/patientsafety/activities/technical/radiotherapy_risk_profile.pdf. Accessed March 31, 2011.
9. Hendee WR Safety and accountability in health care from past to present. Int J Radiat Oncol Biol Phys 2008, 71(Suppl 1):S157-S161.
10. ICRP Publication 112 Preventing accidental exposures from new external beam radiation therapy technologies. Ann ICRP 2009, 39:3-5.
11. Dunscombe P What can go wrong in radiation treatment? 2010, Miami, FL. Available at http://www.aapm.org/meetings/2010SRT/. Accessed March 31, 2011.
12. Ford EC, Terezakis S How safe is safe? Risk in radiotherapy. Int J Radiat Oncol Biol Phys 2010, 78:321-322.
13. Marks LB, Jackson M, Xie L, et al. The challenge of maximizing safety in radiation oncology. Practical Radiat Oncol 2011, 1:2-14.
14. Joint Council for Clinical Oncology Reducing delays in cancer treatment: some targets 1993, Royal College of Physicians and Royal College of Radiologists, London: UK, Available at http://www.rcr.ac.uk/docs/oncology/pdf/reducingdelaysincancertreatment.pdf. Accessed March 31, 2011.
15. Steel GG The growth rate of tumours. Basic clinical radiobiology 1997, 8-13. Edward Arnold, London. 2nd ed. G.G. Steel (Ed.).
16. Richards MA, Westcombe AM, Love SB, Littlejohns P, Ramirez AJ Influence of delay on survival in patients with breast cancer: a systematic review. Lancet 1999, 353:1119-1126.
17. Burnet NG, Benson RJ, Williams MV, Peacock JH Improving cancer outcomes through radiotherapy. Lack of UK radiotherapy resources prejudices cancer outcomes. BMJ 2000, 320:198-199.
18. Wyatt RM, Beddoe AH, Dale RG The effects of delays in radiotherapy treatment on tumour control. Phys Med Biol 2003, 48:139-155.
19. Wyatt RM, Jones BJ, Dale RG Radiotherapy treatment delays and their influence on tumour control achieved by various fractionation schedules. Br J Radiol 2008, 81:549-563.
20. Blumenthal DT, Won M, Mehta MP, et al. Short delay in initiation of radiotherapy may not affect outcome of patients with glioblastoma: a secondary analysis from the Radiation Therapy Oncology Group database. J Clin Oncol 2009, 27:733-739.
21. Gawande A. The checklist manifesto: how to get things right 2009, Metropolitan Books, Henry Holt and Company, LLC, New York, NY. 1st ed.
22. Pronovost PJ, Vohr E. Safe patients, smart hospitals: how one doctor's checklist can help us change health care from the inside out 2010, Hudson Street Press, New York, NY. 1st ed.
23. Wu B. Manufacturing systems design and analysis, context and techniques 1994, Chapman and Hall, London, England. 2nd ed.
24. Chalice R. Improving healthcare using Toyota lean production methods: 46 steps for improvement 2007, American Society for Quality, Quality Press, Milwaukee, WI. 2nd ed.
25. Mazzocato P, Savage C, Brommels M, Aronsson H, Thor J Lean thinking in healthcare: a realist review of the literature. Qual Saf Health Care 2010, 19:376-382.
26. Institute for Safe Medication Practices, Medical Error Prevention Toolbox, ISMP Newsletter, June 2, 1999 Available at, Accessed March 31, 2011. http://www.ismp.org/Newsletters/acutecare/articles/19990602.asp.
27. Rasmussen B, Chu K Implementation of a "time out" procedure in radiation oncology: a multi-institution study over nine years results in a three-fold reduction in misadministrations. Med Phys 2010, 37:3450.
28. Hendee WR, Herman MG Improving patient safety in radiation oncology. Med Phys 2011, 38:78-82.
29. Trusko BE, Pexton C, Harrington J, Gupta PK Improving healthcare quality and cost with six sigma 2007, FT Press, Upper Saddle River, NJ. 1st ed.
30. Riebling NB, Laurel Tria L. Laboratory toolbox for process improvement. Six-sigma at North Shore-Long Island Jewish Health System. Lab Medicine 2008, 39:7-14.
31. Failure mode and effects analysis in healthcare: proactive risk reduction 2005, Joint Commission Resources, Inc, Oakbrook Terrace, IL. 2nd ed.
32. Ford EC, Gaudette R, Myers L, et al. Evaluation of safety in a radiation oncology setting using failure mode and effects analysis. Int J Radiat Oncol Biol Phys 2009, 74:852-858.
33. Spath P. Error reduction in health care: a systems approach to improving patient safety 2011, Jossey-Bass, San Francisco, CA. 2nd ed.
34. Reason J Human error: models and management. BMJ 2000, 320:768-770.
35. Barach P, Small SD Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000, 320:759-763.
36. Williams MV Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol 2007, 80:297-301.
37. Clark BG, Brown RJ, Ploquin JL, Kind AL, Grimard L The management of radiation treatment error through incident learning. Radiother Oncol 2010, 95:344-349.
38. Cunningham J, Coffey M, Knóós T, Holmberg O Radiation Oncology Safety Information System (ROSIS)-profiles of participants and the first 1074 incident reports. Radiother Oncol 2010, 97:601-607.
39. Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ An international review of patient safety measures in radiotherapy practice. Radiother Oncol 2009, 92:15-21.
40. Cafazzo JA, Trbovich PL, Cassano-Piche A, et al. Human factors perspectives on a systemic approach to ensuring a safer medication delivery process. Healthcare Q 2009, 12(Spec No Patient):70-74.
41. Chan AJ, Islam MK, Rosewall T, Jaffray DA, Easty AC, Cafazzo JA The use of human factors methods to identify and mitigate safety issues in radiation therapy. Radiother Oncol 2010, 97:596-600.
42. ElBardissi AW, Wiegmann DA, Dearani JA, Daly RC, Sundt TM Application of the human factors analysis and classification system methodology to the cardiovascular surgery operating room. Ann Thorac Surg 2007, 83:1412-1419.
43. Rivera AJ, Karsh BT Human factors and systems engineering approach to patient safety for radiotherapy. Int J Radiat Oncol Biol Phys 2008, 71(Suppl 1):S174-S177.
44. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009, 360:491-499.
45. Franke RH, Kaul JD The Hawthorne experiments: first statistical interpretation. American Sociological Review 1978, 43:623-643.
46. Lied TR, Kazandjian VA A Hawthorne strategy: implications for performance measurement and improvement. Clin Perform Qual Health Care 1998, 6:201-204.
47. Hsueh Y The Hawthorne experiments and the introduction of Jean Piaget in American industrial psychology, 1929-1932. Hist Psychol 2002, 5:163-189.
48. Morris B Tearing up the Jack Welch playbook. Fortune November 26. 2006.
49. Bell D. Science, technology and culture 2005, Open University Press, McGraw-Hill International, Berkshire, England. 1st ed.
50. Abdel-Wahab M, Rengan R, Curran B, et al. Integrating the healthcare enterprise in radiation oncology plug and play-the future of radiation oncology?. Int J Radiat Oncol Biol Phys 2010, 76:333-336.