Presented by Jeffrey Antone, CMD
Chief Dosimetrist
Center for Advanced Medicine

Recorded September 17, 2019
​From the AAMD 44th Annual Meeting

Promoting a safe culture and minimizing errors has been vital for patient care, especially at a multi-centered radiation oncology department. Dosimetrists play a critical role in treatment planning decisions and working within the department to promote patient safety. However, patients and their patience may be tested when there are delays due to last-minute checks and approvals with their treatment plan. Human error and communication are big contributors to delays in patients starting treatment.RO-ILS (Radiation Oncology Incident Learning System) was implemented at our center September 2017. Our goal was to track and trend events that occurred, catch near misses, and learn from global data provided by Patient Safety Organization. The team combed through hundreds of departmental entries entered within the last year. Events were organized into five categories:
1) Therapeutic radiation incidents;
2) Other safety incidents;
3) Near Misses;
4) Unsafe Conditions;
5) Operational/process improvements.

The RO-ILS team meets bi-weekly to discuss reoccurring incidents, monitor trends, and close the loop with feedback. By providing feedback in the department, this encourages colleagues to submit events without punitive repercussions. Our goal is to build trust and inclusion; we want to show that their concerns are heard and changes are going to be made. Over this year, we were able to examine aspects of our treatment flow processes, propose new policies, and establish a smoother workflow to Vsim. During the evaluation period, we were able to create sub-categories for physics to help provide more details and analysis. Bottom line, delivering the best quality care for our patients in a safer and efficient turnaround time.

Learner Outcomes

1. Implementing a QA system to monitor and change variances in the clinic
2. How to motivate team members in the department to be involved in RO-ILS
3. Demonstrate how the changes made affect the department workflow

Presenter
Jeffrey Antone, CMD is the Chief Dosimetrist in the Radiation Department at the Center for Advanced Medicine in Lake Success, NY. He is currently Secretary on the Annual Conference Committee and a Regional IV Rep for the AAMD.