Dr Tom Roques, Norfolk & Norwich University Hospital

09/01/2013
What can doctors do to
prevent radiotherapy
errors?
Tom Roques
Consultant Clinical Oncologist
Norfolk and Norwich University Hospital
tom.roques@nnuh.nhs.uk
BIR errors meeting September 2012
The problem - level 1
Level 1 errors don’t usually involve doctors directly
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09/01/2013
The problem - level 5
What incidents do doctors
cause?
Thanks to Mark Rose, NNUH
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How to improve?
Awareness that volume definition is an early part of a
complex process
Pre-planning meetings
Dedicated planning and approval time in job plans
(and in reality)
RCR – many oncologists don’t have formal planning
time in job plans. ‘Planning time…needs to be seen
as equating to an operating list’
Overall doctors’ role
Leadership for the whole pathway
A guide to understanding IR(ME)R in radiotherapy 2008
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WHO report
Radiotherapy risk profile
Systematic review of RT errors 1976-2007
Published data and department incident reports
Worldwide
16 separate episodes affecting 3125 patients t - of
whom 38 died due to overdose
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09/01/2013
Radiotherapy risk profile
Medical errors as a whole
UK chief medical officer report 2000 suggested
between 60,000 and 255,000 deaths or serious
disability annually
Current data - 12000 preventable hospital deaths
annually in UK
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09/01/2013
Why so many errors?
Extremely complex hospital working - inevitability
Culture – lack of learning
Lack of systems
Pressure on individuals
Belief that clinical autonomy paramount
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Two main problem areas
• Patient selection for treatment
• Volume definition
How do we choose the right
treatment for the patient?
Selection criteria for radiotherapy relatively vague
Clinical trial selection criteria not applied in real life
Rely on staging (at MDT), PS and intuition
Poor at assessing functional reserve – esp in elderly
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09/01/2013
Huge variation in the UK
Geographical Variation in Radiotherapy Services Across the UK in 2007 and the Effect of Deprivation
M.V. Williams and K.J. Drinkwater Clinical Oncology August 2009
The problem with MDTs
Over-stretched
- all becoming longer and there are
more of them
Perhaps one doctor will have met the patient
The treating oncologist will almost certainly not have
met the patient
So decisions i based on imaging i and path, not patient
t
characterstics and preferences
Little/no evidence to support quality of MDT decision
making
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09/01/2013
Performance status
www.pallimed.org/2008/09/physician-patient-disagreement-about.htmlabout.html
What can we do -
selection?
Meticulous staging to exclude those with metastases from curative
RT
Formal QA of MDTs - dummy patients at MDT, review of blind cases,
revalidation
Need to develop much better tools to select patients on basis of
functional status (overall and organ specific)
Good outcomes data collection by individual clinician - especially in
patients with high rates of metastases
Listen to others – CNSs, radiographers etc. Do they think the
treatment plan is correct
Collaborative oncologist discussion of NPs once seen. Pre planning
meetings
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Volume definition
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09/01/2013
• Ceci n’est nest pas une pipe
Vxv| ÇËxáà Ñtá âÇ ÄâÇz vtÇvxÜ
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PET to improve concordance
Steenbakkers et al. IJROBP 2008
Radiochemotherapy +/- tirapazamine in HN cancer
861 patients, 82 centres in 16 countries
Diagnostic imaging and plans submitted for central
review by end of week 1 of therapy (n=687).
Changes recommended in 197 (29%)
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09/01/2013
QA review of all plans within trial
Further TMC review after trial
closed of all evaluable patients
(n=820)
97 major errors - 24 incorrect
GTV, 41 PTV not covered, 25
incorrect prescription, 7
prolonged treatment
197 plans had major changes recommended during
the study
Of these 89 were implemented - all passed TMC
review
108 not implemented - 95 failed TMC review
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09/01/2013
Conclusions
GTV outlining
• Main source of systematic error in RT
• Have all the information you before you start –
diagnostic imaging, op note, surgeon etc
• View planning CT on PACS screen with the eye of a
radiologist
• Clinical and radiological anatomy
• Never copy slices
• Radiologists defining GTVs?
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Imaging for Oncologists
• UK Royal College of Radiologists 2004
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CTV
• Selection v delineation
• Contouring atlases for
standard nodal CTVs
• Primary CTVs much more of
an art – balance of risks
CTV definition
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To improve volume
definition
Meticulous documentation of MDT discussions
Pre-planning meeting - especially for selection of target
volume
Dedicated time for volume definition (like operating lists)
Very careful review of planning CT
Radiologist/surgeon input to difficult cases
Review all volumes with another clinician – delineation
Take part in clinical trials with QA
To improve volume
definition
Think like a surgeon
Question every bit of every contour all the time
Map your recurrences very carefully
Outsourcing of rarer cases?
Better teaching tools (including radiation oncologists?)
Always remember we are the weakest link and the biggest
source of errors
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09/01/2013
Conclusions
• Take leadership for the whole treatment pathway
• Look for the unknown unknowns
• Refine tools for selecting patients for RT
• GTV is a statement of fact. CTV is a statement of
uncertainty.
ty
• We are not good at either and need help!
Final picture
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