Conflict of Interest. Patient Safety and the Training of the Medical Physicist. Training in Patient Safety

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Patient Safety and the Training of the Medical Physicist Peter Dunscombe, Ph.D. Derek Brown, Ph.D. University of Calgary/ Tom Baker Cancer Centre Conflict of Interest Peter Dunscombe and Derek Brown are Directors of AQuSI LLC www.

1 Patient Safety and the Training of the Medical Physicist Peter Dunscombe, Ph.D. Derek Brown, Ph.D. University of Calgary/ Tom Baker Cancer Centre Conflict of Interest Peter Dunscombe and Derek Brown are Directors of AQuSI LLC Education Council Symposium 31 st July 2011 Conflict of Interest Ethics and Errors Course Learning Objectives 1. To establish the objectives and constraints in the design of a training program in error management/patient safety. 2. To consider examples of how the objectives of such a program were met by the Calgary course on Ethics and Errors. 3. To briefly review participants assessments of the four courses run so far. 4. To take a short diversion into Ethics education. 1

2 Patient Safety Training: Why? Why develop a training program in Patient Patient Safety Training: Why? Another reason: One conclusion of the Miami meeting Patient safety should be a (ABR) competency Herman and Hendee: Med Phys 38 (2011) Ms Lisa Norris Glasgow Incident, January

3 Patient Safety Training: Why? And yet another reason ASTRO UK WHO ICRP Hierarchy TG 100 Quality Audits Incident Learning Other high impact Document ation - - Education Training - - In addition - - Top 3 Intermediate Weak Patient Safety Training: Why? And then there s a local reason The Tom Baker Cancer Centre/University of Calgary CAMPEP accredited Residency /Post Ph.D. Diploma and Graduate Programs were missing (at least) two competencies: Error Management Ethics Patient Safety Training: Objectives and Constraints Objectives Following Hendee and Herman we can identify the Objectives of the training to develop competency in patient safety. Where competency can be defined as to be able to adequately perform a professional act in a specific environment by integrating knowledge, skills and attitude * * definition borrowed from ESTRO 3

4 Patient Safety Training: Objectives and Constraints Constraints Schedule can be accommodated within a university semester. Material can be understood and appreciated by a multidisciplinary audience. Material is (more or less) within the realm of the knowledge and experience of the instructors. The Plan Develop competency by integrating Knowledge (transfer) Skill (develop) Attitude (foster) The Format 7 x 2hr Sessions Lectures (~50%) Group exercises (~50%) Lively discussions No homework No grading of students 4

5 Imaging Assessment Physical Level 1 Level 2 Level 3 Pathology Decision to Treat Preparation for Prescription PTV/OAR Definition Prescription Clinical Protocol Immobilization Therapy Imaging Dose Calculation Independent Dose Calculation Preparation for Delivery DRRs Experimental Validation Patient/File correspondence Delivery Transfer to DMS Patient Set-up Follow-up Knowledge Transfer Process Maps (15 slides) Root Cause Analysis (55 slides) Failure Modes and Effects Analysis (45 slides) Fault Tree Analysis (38 slides) Preventive Measures (36 slides) Knowledge Transfer Process Maps (15 slides) Root Cause Analysis (55 slides) Failure Modes and Effects Analysis (45 slides) Fault Tree Analysis (38 slides) Preventive Measures (36 slides) Knowledge: Process Maps Knowledge: Process Tree Process maps and trees are discussed in general. Patient Specific Activities Process maps and trees from the literature are presented, e.g. Ford et al., TG100. Uses of process maps are discussed. 20 5

6 Knowledge: Root Cause Analysis ANY Incident: Intermediate Diagram Principles and methodology of RCA are presented. An RCA loosely based on the New York State incident is worked through. One patient overdosed Revised plan sent to machine New plan done RO prescribes new volume Patient already received 4 fractions What was the Plan reviewed at Complex or simple Rapid change Any problems Approaches to RCA developed by different organizations are similar. The VA description has been used to date in the example. overdose? Single or multiple fractions? machine? plan? Plan approved? required? encountered? Patient specific issues? ANY Incident: Cause and Effect Skill Development Beam not verified See next slide Process Maps Root Cause Analysis Failure Modes and Effects Analysis 39 Gy in 3 fractions MLC file incorrect MLC icon not observed Both RTs watching patient Lack of instructions/ training Lack of Risk awareness Fault Tree Analysis TPS system fault 6

Skill Development Process Maps Root Cause Analysis Failure Modes and Effects Analysis Fault Tree Analysis Skill: Process Maps Participants design a process map describing, for example, a breast

7 Skill Development Process Maps Root Cause Analysis Failure Modes and Effects Analysis Fault Tree Analysis Skill: Process Maps Participants design a process map describing, for example, a breast treatment, TG 51 calibration, etc. The process map is used in a later class as the basis of an FMEA. Skill: Process Maps Skill: Root Cause Analysis The exercise is based on the Ottawa orthovoltage incident. The Instructor plays the role of the Institutional Representative. The Students play the roles of the Incident Reviewers. The Students then perform a Root Cause Analysis based on the information available and according to the methodology discussed. 7

8 Relative Complexity C. Incorrect output tables were prepared during recommissioning C1. Multiple significant tasks assigned to physicists C1a. Inadequate medical physics staffing for routine clinical work C1b. New programs and equipment implementations during a short time period C1bi. Cultural norm did not reflect criticality of medical physics in project management C1ai. Staff shortage due to multiple reasons C1aii. Inadequate staffing standards for medical physics Fostering Attitude (Safety culture and multidisciplinary problem solving) A. 326 patients underdosed B. Incorrect output tables were released for clinical use D. A comprehensive, independent second check was not performed C2. Lack of formal written protocol for orthovoltage (re) commisioning D1. Inadequate time to fully perform second check C2a. Lack of national and provincial protocols for commissioning D1a. Clinical pressure to resume patient treatments C2b. Low priority of orthovoltage compared to other radiation units. D1b. Cultural norm did not reflect criticality of medical physics in project management Safety Awareness IAEA slide set (68 slides) Human Factors (31 slides) D2. Lack of formal written protocol for second check D2a. Lack of national and provincial protocols for commissioning D2b. Low priority of orthovoltage compared to other radiation units. Incident Learning (81 slides) E. Error was not detected for three years E1. Lack of formal written protocol for orthovoltage quality control E1a. Lack of national and provincial protocols for quality control E1b. Low priority of orthovoltage compared to other radiation units. Quality Management (50 slides) E2. Magnitude of error was not easy to detect. Safety Awareness IAEA Slide Set terial/accidentpreventionradiotherapy.htm 1st example: 2nd example: 3rd example: 4th example: 5th example: Incorrect manual parameter transfer (UK) Reversal of images (USA) Inappropriate measuring device (France) Erroneous calculation for soft wedges (France) Incorrect IMRT planning (USA) Human Factors: Performance Categories after Reason and Hobbs Managing Maintenance Error Straightforward Complex Rare Knowledge Rule Skill Relative Frequency Frequent 8

Incident Learning Quality Management: 1 hour M.B.A. Strategy Effectiveness Resources Priority Comments A Reference Guide for Learning from Incidents in Radiation Treatment www.ihe.

9 Incident Learning Quality Management: 1 hour M.B.A. Strategy Effectiveness Resources Priority Comments A Reference Guide for Learning from Incidents in Radiation Treatment 1 Checks and verifications should be performed independently by entitled operators working to clear protocols, which make explicit the individual s responsibilities and accountability. 2 Information about an error should be shared as early as possible during or after the investigation. 3 In vivo dosimetry should be used at the beginning of treatment for most patients. 4 All procedures should be documented and subject to review every two years or whenever there are significant changes. 5 The radiotherapy department management structure should be reviewed every two years. Quality Safety Calgary Ethics and Errors Course: Errors Modules /3 Recent Incidents IAEA PD Human Factors lecture PD 15/3 Incident Learning lecture PD Basic Causes exercise PD 17/3 Preventive Measures lecture PD Process Maps and Trees exercise PD 22/3 Root Cause Analysis lecture PD Root Cause Analysis exercise PD 23/3 Failure Modes and Effects Analysis lecture PD Failure Modes and Effects Analysis exercise PD 29/3 Fault Tree Analysis lecture DB Fault Tree Analysis exercise DB 31/3 Quality Management lecture PD 1 hour MBA exercise PD 9

10 Patient Safety Training: Program Outcome Outcome: courses delivered Tom Baker Cancer Centre: Fall 2009 and Winter medical physics residents, 3 radiation oncology residents, 2 radiation therapists. AQuSI : La Jolla, Fall 2010 and Philadelphia, Spring physicists, 1 rad onc, 1 rad onc resident, 5 radiation therapists, 3 commercial Patient Safety Training: Program Outcome Outcome: reviews Tom Baker Cancer Centre: Winter 2011 Done Very Well >95% on 22 point evaluation by seven students. AQuSI : Philadelphia, Spring 2011 Very intense but very complete. Highly interactive presentations. Important topic with practical examples. Patient Safety Training: Ethics Modules Largely based on: Ethics Modules Recommended ethics curriculum for medical physics graduate and residency programs: Report of Task Group 159. Medical Physics. 37: Modules also developed by Harold Lau, M.D., radiation oncologist, and Ron Anderson, M.D., pediatric oncologist 10

Patient Safety Training: Ethics Modules Calgary Ethics and Errors Course: Ethics Modules 2011 Patient Safety Training: Ethics Modules Ethics Group Exercise 5/4 History of ethical thought lecture PD

11 Patient Safety Training: Ethics Modules Calgary Ethics and Errors Course: Ethics Modules 2011 Patient Safety Training: Ethics Modules Ethics Group Exercise 5/4 History of ethical thought lecture PD Values and Codes of Conduct exercise PD 7/4 Professional Ethics lecture HL Professional Ethics exercise HL 12/4 Research Ethics lecture DB Research Ethics exercise DB 14/4 Human Research Ethics lecture HL Human Research Ethics exercise HL 19/4 Ethics in Education lecture RA Ethics in Education exercise RA You are a medical physicist with 5 years experience in a large academic centre. You and your new boss are not seeing eyeto-eye on many things. Therefore, you are thinking about leaving. You have applied to 3 centers, 2 larger urban centers and a third smaller peripheral center in a small town Your first interview offer is with the smaller center Although you are hoping for a job at one of the two larger centers, you are wondering if you should still proceed with interviewing in the smaller center just for the experience. Discuss how you would proceed. Patient Safety Training: Free stuff 11

12 Patient Safety Training: Free stuff Calgary Ethics and Errors Course Patient Safety Training: Free stuff Ethics and Errors Course Each CD contains: 5 Ethics Modules and 7 Errors Modules. Each Module contains: Overview Powerpoint presentations Notes for instructors Exercise material Patient Safety Training: Free stuff AQuSI On-line Course Course presentations are available in iphone and ipad compatible versions. Overview Human Factors Error Management Techniques Quality and Safety Each module comprises 2 fifteen minute presentations, and 2 multiple-choice quizzes. Upon successful completion of all quizzes, a certificate of completion is available for download. 12

We have briefly reviewed participants assessments of the four courses run so far. 4. We have taken a short diversion into Ethics education. Acknowledgements Derek Brown, Ph.D. Robert Lee, M.Sc.

13 Summary 1. We have reviewed the objectives and constraints in the design of a training program in error management/patient safety. 2. We have considered examples of how the objectives of the program were met by the Calgary course on Ethics and Errors. 3. We have briefly reviewed participants assessments of the four courses run so far. 4. We have taken a short diversion into Ethics education. Acknowledgements Derek Brown, Ph.D. Robert Lee, M.Sc. Brenda Clark, Ph.D. Sasa Mutic, M.Sc. David Cooke, Ph.D. Todd Pawlicki, Ph.D. Marilyn Gackle, RTT Jodi Ploquin, M.Sc. Lisa Graham TG 100 Ola Holmberg, Ph.D. ICRP A Seven Part Textbook 1. Quality Management & Improvement 2. Patient Safety & Managing Error 3. Methods to Assure & Improve Quality 4. People & Quality 5. Quality Assurance in Radiotherapy 6. Quality Control: Equipment 7. Quality Control: Patient-Specific 100 Chapters 80 Institutions 16 Countries 13

Tools for risk assessment in radiation therapy

Tools for risk assessment in radiation therapy ICRP Symposium on the International System of Radiological Protection October 24-26, 2011 Bethesda, MD, USA Dr. Pedro Ortiz López ICRP Committee 3 Task