Patient Safety Through the 2010’s & Beyond: A Focused Perspective
By: Jeff Simon, C.E.O., Sun Nuclear Corporation
This article reflects the perspective of Sun Nuclear and our peers who are exclusively focused on Patient Safety.
The World Health Organization (WHO) defines patient safety as “the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.” Global awareness of patient safety continues to increase, as demonstrated by the 2019 designation of September 17 as annual World Patient Safety Day and ASTRO’s 2019 release of the updated Safety is No Accident framework, originally released in 2012.
When looking at RT patient safety progress over the past decade, it is helpful to frame it in terms of upstream and downstream patient safety. Upstream, patient safety is shaped by the quality of the RT treatment technology. Progress here has been considerable, with IGRT, MLC-based stereotactic, and VMAT technologies becoming widespread. These technologies can improve patient safety by providing higher quality and safer treatments. Downstream, patient safety is shaped by the ability to monitor and improve the quality of the fulfillment of RT technology. Here too, capabilities have progressed significantly. Once abstract technologies such as 3-D anatomical dose verification and in-vivo monitoring have become widely available, improving the ability to detect myriad intra- and inter-fraction patient and machine errors. These downstream technologies improve patient safety by enabling clinicians to answer the critical question: was the Rx delivered as intended?
Much more work remains to be done to support a continued culture of patient safety in RT. As one of several companies focused exclusively on patient safety, we see three key areas for improvement as we enter the next decade. The first is improving our understanding of the importance of independent downstream Patient Safety checks, or QA. Today’s RT systems are so complex that it is simply not possible to internally mitigate every potential risk without independent routine checks. ASTRO’s Safety is No Accident Framework specifically calls out “independent” no less than 11 times when describing details of a framework for quality RT care. The second is improving access to data. Open access to machine and treatment data is critical for independent evaluation of the quality of RT fulfillment. A 2019 publication revealed that in a single year, a site identified 4,000 actionable errors and opportunities for improvement within 56,000 delivered fractions. These discoveries directly benefit all parties including the clinic, the patient and the delivery vendor, and are made possible by independent downstream QA and access to data. The third is avoiding the risk of complacency. As with all complex systems which are typically stable, safety can be taken for granted, until it is too late.
RT patient safety progress is not static and is shaped by upstream treatment technology, the clinical use of that technology and independent downstream checks and balances that verify, monitor and improve that technology. When we are informed, proactive and work together, we establish the best possible environment to continue to enhance patient safety and advance RT for cancer treatment.
This article reflects the perspective of Sun Nuclear and our peers who are exclusively focused on Patient Safety.
The World Health Organization (WHO) defines patient safety as “the absence of preventable harm to a patient during the process of health care and reduction of risk of unnecessary harm associated with health care to an acceptable minimum.” Global awareness of patient safety continues to increase, as demonstrated by the 2019 designation of September 17 as annual World Patient Safety Day and ASTRO’s 2019 release of the updated Safety is No Accident framework, originally released in 2012.
When looking at RT patient safety progress over the past decade, it is helpful to frame it in terms of upstream and downstream patient safety. Upstream, patient safety is shaped by the quality of the RT treatment technology. Progress here has been considerable, with IGRT, MLC-based stereotactic, and VMAT technologies becoming widespread. These technologies can improve patient safety by providing higher quality and safer treatments. Downstream, patient safety is shaped by the ability to monitor and improve the quality of the fulfillment of RT technology. Here too, capabilities have progressed significantly. Once abstract technologies such as 3-D anatomical dose verification and in-vivo monitoring have become widely available, improving the ability to detect myriad intra- and inter-fraction patient and machine errors. These downstream technologies improve patient safety by enabling clinicians to answer the critical question: was the Rx delivered as intended?
Much more work remains to be done to support a continued culture of patient safety in RT. As one of several companies focused exclusively on patient safety, we see three key areas for improvement as we enter the next decade. The first is improving our understanding of the importance of independent downstream Patient Safety checks, or QA. Today’s RT systems are so complex that it is simply not possible to internally mitigate every potential risk without independent routine checks. ASTRO’s Safety is No Accident Framework specifically calls out “independent” no less than 11 times when describing details of a framework for quality RT care. The second is improving access to data. Open access to machine and treatment data is critical for independent evaluation of the quality of RT fulfillment. A 2019 publication revealed that in a single year, a site identified 4,000 actionable errors and opportunities for improvement within 56,000 delivered fractions. These discoveries directly benefit all parties including the clinic, the patient and the delivery vendor, and are made possible by independent downstream QA and access to data. The third is avoiding the risk of complacency. As with all complex systems which are typically stable, safety can be taken for granted, until it is too late.
RT patient safety progress is not static and is shaped by upstream treatment technology, the clinical use of that technology and independent downstream checks and balances that verify, monitor and improve that technology. When we are informed, proactive and work together, we establish the best possible environment to continue to enhance patient safety and advance RT for cancer treatment.
