Quality assurance analysis of a large multicenter practice: does increased complexity of intensity-modulated radiotherapy lead to increased error frequency?

Int J Radiat Oncol Biol Phys. 2012 Jan 1;82(1):e77-82. doi: 10.1016/j.ijrobp.2011.01.033. Epub 2011 Apr 15.

Abstract

Purpose: Error reduction is an important concern in clinical medicine. Intensity-modulated radiotherapy (IMRT) is an important advancement in radiation oncology that increases the complexity of treatment, potentially increasing the error risk. We studied the frequency and severity of errors in a large multicenter practice to ascertain the impact of quality improvement interventions over time, IMRT, and type of practice.

Methods and materials: We analyzed prospective data from three academic and 16 community practice sites with 24,775 courses of radiotherapy (9,210 IMRT courses and 15,565 non-IMRT) between January 2006 and December 2009. All IMRT treatment was performed using one centralized dose planning center for all sites.

Results: We prospectively identified various errors or potential errors in 0.14 % vs. 0.40 % of the IMRT vs. non-IMRT courses (13/9,210 vs. 62/15,565, p = 0.0004) and excluding potential errors: 0.03 % for IMRT vs. 0.21% for non-IMRT. We developed the Clinical Radiotherapy Error Severity Scale (CRESS) to classify error severity from 1 to 10, with 1 to 3 for potential or completely correctable errors, 4 to 5 for dose variations <5%, and 6 to 10 for dose variations >5%. Multivariate analyses of CRESS values, severity >4, and any error (including potential) correlated significantly reduced errors with IMRT (p = 0.0001-0.0024) but found no significant difference between the academic and community practice sites and no change in error frequency over time despite implementation of 39 system-wide policy changes by the centralized quality improvement committee.

Conclusions: Despite the increase in complexity with IMRT compared with conventional radiotherapy, it can be delivered with reduced error frequency.

Publication types

  • Comparative Study

MeSH terms

  • Humans
  • Logistic Models
  • Medical Errors / adverse effects
  • Medical Errors / classification
  • Medical Errors / statistics & numerical data*
  • Multi-Institutional Systems / standards*
  • Multi-Institutional Systems / statistics & numerical data
  • Multivariate Analysis
  • Prospective Studies
  • Quality Control
  • Radiotherapy Dosage
  • Radiotherapy Planning, Computer-Assisted / methods
  • Radiotherapy, Intensity-Modulated / adverse effects
  • Radiotherapy, Intensity-Modulated / methods*
  • Radiotherapy, Intensity-Modulated / standards
  • Radiotherapy, Intensity-Modulated / statistics & numerical data
  • Severity of Illness Index