Patient Safety and the
Training of the Medical
Physicist
Conflict of Interest
Peter Dunscombe, Ph.D.
Derek Brown, Ph.D.
Peter Dunscombe and Derek Brown
are Directors of AQuSI LLC
University of Calgary/
Tom Baker Cancer Centre
www.aqusi.org
Education Council Symposium
31st July 2011
Conflict of Interest
Training in Patient Safety
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
Training in Patient Safety
Training in Patient Safety
Outline
1. Why develop a training program in Patient
Safety?
Outline
1. Why develop a training program in Patient
Safety?
2. Program objectives and constraints
2. Program objectives and constraints
3. Program plan, format and implementation
3. Program plan, format and implementation
4. Program outcome
4. Program outcome
5. A diversion into Ethics
5. A diversion into Ethics
6. Free stuff
6. Free stuff
7. Summary
7. Summary
Patient Safety Training: Why?
Why develop a training program
in Patient Safety?
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) 78-82
Ms Lisa Norris – Glasgow Incident, January 2006
2
Patient Safety Training: Why?
Patient Safety Training: Why?
And then there’s a local reason
And yet another reason
ASTRO
UK
WHO
ICRP
Quality
Audits
√
√
Other
high
impact
√
Incident
Learning
√
√
In
addition
√
-
√
√
√
Document
ation
Education
Training
Top 3
Hierarchy
TG 100
-
-
-
-
√
Intermediate
√
√
Weak
√
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
http://ucalgary.ca/rop/
Patient Safety Training: Objectives and Constraints
Training in Patient Safety
Objectives
Outline
1. Why develop a training program in Patient
Safety?
2. Program objectives and constraints
• Following Hendee and Herman we can identify
the Objectives of the training to develop
competency in patient safety.
5. A diversion into Ethics
• 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”*
6. Free stuff
* definition borrowed from ESTRO
3. Program plan, format and implementation
4. Program outcome
7. Summary
3
Patient Safety Training: Objectives and Constraints
Constraints
Training in Patient Safety
Outline
• Schedule can be accommodated within a
university semester.
1. Why develop a training program in Patient
• Material can be understood and appreciated
by a multidisciplinary audience.
2. Program objectives and constraints
• Material is (more or less) within the realm of
the knowledge and experience of the
instructors.
Safety?
3. Program plan, format and implementation
4. Program outcome
5. A diversion into Ethics
6. Free stuff
7. Summary
Patient Safety Training: Program Plan
The Plan
Patient Safety Training: Program Plan
The Format
Develop competency by integrating
• 7 x 2hr Sessions
• Knowledge (transfer)
• Lectures (~50%)
• Skill (develop)
• Group exercises (~50%)
• Attitude (foster)
• Lively discussions
• No homework
• No grading of students
4
Patient Safety Training: Program Plan
Patient Safety Training: Program Plan
Knowledge Transfer
Knowledge Transfer
• Process Maps (15 slides)
• Process Maps (15 slides)
• Root Cause Analysis (55 slides)
• Root Cause Analysis (55 slides)
• Failure Modes and Effects Analysis (45 slides)
• Failure Modes and Effects Analysis (45 slides)
• Fault Tree Analysis (38 slides)
• Fault Tree Analysis (38 slides)
• Preventive Measures (36 slides)
• Preventive Measures (36 slides)
Patient Safety Training: Program Plan
Patient Safety Training: Program Plan
Knowledge: Process Tree
Knowledge: Process Maps
• Process maps and trees are discussed in
general.
Patient Specific Activities
Decision to
Treat
Assessment
• Process maps and trees from the literature are
presented, e.g. Ford et al., TG100.
Imaging
Preparation for
Prescription
PTV/OAR
Definition
Pathology
Preparation for
Delivery
Prescription
Delivery
Patient/File
correspondence
Clinical Protocol
Follow-up
Patient Set-up
Physical
• Uses of process maps are discussed.
Immobilization
Therapy Imaging
Dose Calculation
Independent Dose
Calculation
DRRs
Transfer to DMS
Experimental
Validation
Level 1
Level 2
Level 3
20
5
Patient Safety Training: Program Plan
Patient Safety Training: Program Plan
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.
• Approaches to RCA developed by different
organizations are similar. The VA description
has been used to date in the example.
Patient Safety Training: Program Plan
Revised plan sent
to machine
New plan done
RO prescribes
new volume
Patient already
received 4
fractions
What was the
overdose?
Plan reviewed at
machine?
Complex or simple
plan?
Rapid change
required?
Any problems
encountered?
Single or multiple
fractions?
Plan approved?
Patient specific
issues?
Patient Safety Training: Program Plan
ANY Incident: Cause and Effect
Beam not verified
One patient
overdosed
Skill Development
• Process Maps
See next slide
• 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
Patient Safety Training: Program Plan
Skill Development
• Process Maps
• Root Cause Analysis
• Failure Modes and Effects Analysis
• Fault Tree Analysis
Patient Safety Training: Program Plan
Skill: Process Maps
Patient Safety Training: Program Plan
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.
Patient Safety Training: Program Plan
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
Patient Safety Training: Program Plan
Patient Safety Training: Program Plan
C1. Multiple
significant tasks
assigned to
physicists
C1b. New programs
and equipment
implementations
during a short time
period
C1bi. Cultural norm
did not reflect
criticality of medical
physics in project
management
C2. Lack of formal
written protocol for
orthovoltage (re)
commisioning
C2a. Lack of
national and
provincial
protocols for
commissioning
C2b. Low priority
of orthovoltage
compared to other
radiation units.
D1. Inadequate
time to fully
perform second
check
D1a. Clinical
pressure to
resume patient
treatments
D1b. Cultural norm
did not reflect
criticality of medical
physics in project
management
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.
C. Incorrect output
tables were prepared
during
recommissioning
A. 326 patients
underdosed
B. Incorrect output
tables were released
for clinical use
D. A
comprehensive,
independent
second check was
not performed
C1ai. Staff
shortage due to
multiple reasons
C1a. Inadequate
medical physics
staffing for routine
clinical work
E1. Lack of formal
written protocol for
orthovoltage quality
control
E. Error was not
detected for three
years
E1a. Lack of
national and
provincial
protocols for
quality control
Fostering Attitude
C1aii. Inadequate
staffing standards
for medical
physics
E1b. Low priority
of orthovoltage
compared to other
radiation units.
(Safety culture and multidisciplinary problem solving)
•
Safety Awareness – IAEA slide set (68 slides)
•
Human Factors (31 slides)
•
Incident Learning (81 slides)
•
Quality Management (50 slides)
E2. Magnitude of
error was not easy
to detect.
• 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)
after Reason and Hobbs – Managing Maintenance Error
Complex
http://rpop.iaea.org/RPOP/RPoP/Content/AdditionalResources/Training/1_TrainingMa
terial/AccidentPreventionRadiotherapy.htm
Human Factors: Performance Categories
Relative Complexity
Safety Awareness
IAEA Slide Set
Patient Safety Training: Program Plan
Knowledge
Rule
Straightforward
Patient Safety Training: Program Plan
Skill
Rare
Frequent
Relative Frequency
8
Patient Safety Training: Program Plan
Patient Safety Training: Program Plan
Quality Management: 1 hour M.B.A.
Incident Learning
Strategy
Effectiveness
Quality
A Reference Guide for Learning
from Incidents in Radiation
Treatment
www.ihe.ca/publications/library/archived/a-reference-guide-for-learning-fromincidents-in-radiation-treatment/
Resources Priority
Comments
Safety
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.
Patient Safety Training: Program Plan
Calgary Ethics and Errors Course:
Training in Patient Safety
Errors Modules 2011
10/3
15/3
17/3
22/3
23/3
29/3
31/3
Recent Incidents
IAEA
PD
Human Factors
lecture
PD
Incident Learning
lecture
PD
Basic Causes
exercise
PD
Preventive Measures
lecture
PD
Process Maps and Trees
exercise
PD
Root Cause Analysis
lecture
PD
Root Cause Analysis
exercise
PD
Failure Modes and Effects Analysis
lecture
PD
Failure Modes and Effects Analysis
exercise
PD
Fault Tree Analysis
lecture
DB
Fault Tree Analysis
exercise
DB
Quality Management
lecture
PD
1 hour MBA
exercise
PD
Outline
1. Why develop a training program in Patient
Safety?
2. Program objectives and constraints
3. Program plan, format and implementation
4. Program outcome
5. A diversion into Ethics
6. Free stuff
7. Summary
9
Patient Safety Training: Program Outcome
Patient Safety Training: Program Outcome
Outcome: reviews
Outcome: courses delivered
Tom Baker Cancer Centre:
Tom Baker Cancer Centre:
Fall 2009 and Winter 2011
Winter 2011
2 medical physics residents, 3 radiation oncology
residents, 2 radiation therapists.
“Done Very Well” >95% on 22 point evaluation
by seven students.
AQuSI :
AQuSI :
La Jolla, Fall 2010 and Philadelphia, Spring 2011
Philadelphia, Spring 2011
8 physicists, 1 rad onc, 1 rad onc resident, 5
radiation therapists, 3 commercial
“Very intense but very complete. Highly
interactive presentations. Important topic with
practical examples.”
Patient Safety Training: Ethics Modules
Training in Patient Safety
Outline
1. Why develop a training program in Patient
Safety?
2. Program objectives and constraints
3. Program plan, format and implementation
4. Program outcome
5. A diversion into Ethics
6. Free stuff
Ethics Modules
• Largely based on:
“Recommended ethics curriculum for medical
physics graduate and residency programs:
Report of Task Group 159.”
Medical Physics. 37:4495-4501. 2010
• Modules also developed by Harold Lau, M.D.,
radiation oncologist, and Ron Anderson, M.D.,
pediatric oncologist
7. Summary
10
Patient Safety Training: Ethics Modules
Patient Safety Training: Ethics Modules
Calgary Ethics and Errors Course:
Ethics Modules 2011
5/4
7/4
12/4
14/4
19/4
History of ethical thought
lecture
PD
Values and Codes of Conduct
exercise
PD
Professional Ethics
lecture
HL
Professional Ethics
exercise
HL
Research Ethics
lecture
DB
Research Ethics
exercise
DB
Human Research Ethics
lecture
HL
Human Research Ethics
exercise
HL
Ethics in Education
lecture
RA
Ethics in Education
exercise
RA
Ethics Group Exercise
• 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
Training in Patient Safety
Outline
1. Why develop a training program in Patient
Safety?
2. Program objectives and constraints
3. Program plan, format and implementation
4. Program outcome
5. A diversion into Ethics
6. Free stuff
7. Summary
11
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
Training in Patient Safety
Outline
Course presentations are available in iPhone and iPad
compatible versions.
1. Why develop a training program in Patient
Safety?
•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.
2. Program objectives and constraints
3. Program plan, format and implementation
4. Program outcome
5. A diversion into Ethics
6. Free stuff
7. Summary
12
Training in Patient Safety
Acknowledgements
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
Derek Brown, Ph.D.
Brenda Clark, Ph.D.
David Cooke, Ph.D.
Marilyn Gackle, RTT
Lisa Graham
Ola Holmberg, Ph.D.
Robert Lee, M.Sc.
Sasa Mutic, M.Sc.
Todd Pawlicki, Ph.D.
Jodi Ploquin, M.Sc.
TG 100
ICRP
the four courses run so far.
4.
We have taken a short diversion into Ethics education.
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