"Medical error" and radiation

BACKGROUND:  Osteoarthritis of the first carpometacarpal (CMC) joint, also known as rhizarthrosis, is one of the most common diseases of the hand. Multiple medical and paramedical disciplines can be involved in the treatment. Interventional and surgical treatments may have a risk of complications and thus also of medical malpractice. In this paper, cases of medical malpractice in treatments of rhizarthrosis were analysed, in order to evaluate the quality of medical care. PATIENTS AND METHODS:  Cases of medical malpractice with the diagnosis "Rhizarthrosis" (ICD-10 M18) from 2010 until 2018 were provided by the Arbitration Board for Medical Liability Issues of the Medical Associations of North Germany...

Medical errors are currently ranked the third leading cause of death in United States; however, hospital responses when one occurs have been left out of organizational crisis and image repair literature. This article reports an image repair analysis of the 2010 CoxHealth radiation medical error case, when 76 patients accidentally received fatally high doses of radiation for the treatment of brain cancer. CoxHealth used a variety of image repair strategies including shifting the blame, minimization, bolstering, and corrective action...

PURPOSE: Previous studies suggest that within radiation oncology, medical physicists (MP) experience high workloads. Little is known about how MPs use social support (SS) in times of stress. METHODS: In collaboration with the Workgroup on Prevention of Medical Error, the American Association of Physicists in Medicine administered this Human Investigation Committee (HIC) approved email survey to 8566 members. Respondents were considered likely to seek SS if they answered (probably/definitely would) and unlikely to seek support if they answered (probably/definitely would not)...

BACKGROUND: Medical errors in radiation oncology (RO) practice have received significant national attention over the last decade. Medical errors can lead to malpractice cases. Better characterizing these events can educate providers with the goal of improving patient care. METHODS: The REMOVED FOR BLINDING Comparative Benchmarking System (CBS) represents approximately 30% of all closed US malpractice cases and includes the experience of over 30 academic hospitals...

Assessing the quality of health care delivered is a priority across medical specialties, but it is particularly critical for radiation oncology, a field with rapid introduction of new technologies and treatment paradigms. Deviation from acceptable standards can lead to delivery of inferior therapies and medical errors that can directly compromise patient clinical outcome, thus leading to disparities in quality of care. Professional oncologic specialty societies often take ownership of standardizing best practices by issuing evidence-based disease-specific consensus guidelines...

PURPOSE: Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement...

For the first 180 years following the founding of the US, physicians occasionally were sued for medical malpractice. Allegations of negligence were errors of commission - i.e. the physician made a mistake by doing something wrong, usually mistreatment of a fracture or dislocation, a complication or death following a surgical procedure, prescribing the wrong medication, and after the discovery of the X-ray by Roentgen in 1895, causing radiation burns. In the mid twentieth century malpractice allegations slowly changed from errors of commission to errors of omission - i...

Incident learning is a key component for maintaining safety and quality in healthcare. Its use is well established and supported by professional society recommendations, regulations and accreditation, and objective evidence. There is an active interest in incident learning systems (ILS) in radiation oncology, with over 40 publications since 2010. This article is intended as a comprehensive topic review of ILS in radiation oncology, including history and summary of existing literature, nomenclature and categorization schemas, operational aspects of ILS at the institutional level including event handling and root cause analysis, and national and international ILS for shared learning...

PURPOSE: The anthropomorphic phantom program at the Houston branch of the Imaging and Radiation Oncology Core (IROC-Houston) is an end-to-end test that can be used to determine whether an institution can accurately model, calculate, and deliver an intensity modulated radiation therapy dose distribution. Currently, institutions that do not meet IROC-Houston's criteria have no specific information with which to identify and correct problems. In the present study, an independent recalculation system was developed to identify treatment planning system (TPS) calculation errors...

PURPOSE: To examine characteristics of medical malpractice claims involving radiation oncologists closed during a 10-year period. METHODS AND MATERIALS: Malpractice claims filed against radiation oncologists from 2003 to 2012 collected by a nationwide liability insurance trade association were analyzed. Outcomes included the nature of claims and indemnity payments, including associated presenting diagnoses, procedures, alleged medical errors, and injury severity...

Ionizing radiation (IR) directly damages cells and tissues or indirectly damages them through reactive free radicals that may lead to longer term adverse sequelae such as cancers, persistent inflammation, or possible death. Potential exposures include nuclear reactor accidents, improper disposal of equipment containing radioactive materials or medical errors, and terrorist attacks. Metabolomics (comprehensive analysis of compounds <1 kDa) by mass spectrometry (MS) has been proposed as a tool for high-throughput biodosimetry and rapid assessment of exposed dose and triage needed...

PURPOSE: To develop a robust and efficient process that detects relevant dose errors (dose errors of ≥5%) in external beam radiation therapy and directly indicates the origin of the error. The process is illustrated in the context of electronic portal imaging device (EPID)-based angle-resolved volumetric-modulated arc therapy (VMAT) quality assurance (QA), particularly as would be implemented in a real-time monitoring program. METHODS: A Swiss cheese error detection (SCED) method was created as a paradigm for a cine EPID-based during-treatment QA...

PURPOSE: Radiation oncology relies on rapidly evolving technology and highly complex processes. The US Food and Drug Administration collects reports of adverse events related to medical devices. We sought to characterize all events involving radiation oncology devices (RODs) from the US Food and Drug Administration's postmarket surveillance Manufacturer and User Facility Device Experience (MAUDE) database, comparing these with non-radiation oncology devices. METHODS AND MATERIALS: MAUDE data on RODs from 1991 to 2015 were sorted into 4 product categories (external beam, brachytherapy, planning systems, and simulation systems) and 5 device problem categories (software, mechanical, electrical, user error, and dose delivery impact)...

PURPOSE: Intraoperative radiation therapy (IORT) is a form of breast irradiation that is delivered in a single session at the time of partial mastectomy. In up to 10% of patients, planned IORT is not completed; this leads to wasted resources and decreased patient satisfaction. Our objective was to evaluate factors associated with failure to complete planned IORT. METHODS AND MATERIALS: An IRB-approved review of planned IORT cases from 2011 to 2015 was conducted...

OBJECTIVE: To investigate medical errors in the operating room, attitudes of healthcare professionals in case of errors and educational needs of professionals. METHODS: The descriptive study was conducted at a university hospital in Turkey from January 25 to February 14, 2011, and comprised operating room staff, including physicians, nurses, anaesthesia technicians and perfusion technicians. Data was obtained using a questionnaire. RESULTS: Of the 69 respondents, 45(65...

PURPOSE: To describe radiation therapy cases during which voluntary incident reporting occurred; and identify patient- or treatment-specific factors that place patients at higher risk for incidents. METHODS AND MATERIALS: We used our institution's incident learning system to build a database of patients with incident reports filed between January 2011 and December 2013. Patient- and treatment-specific data were reviewed for all patients with reported incidents, which were classified by step in the process and root cause...

PURPOSE: Patient care within radiation oncology extends beyond the clinic or treatment hours. The on-call radiation oncologist is often not a patient's primary radiation oncologist, introducing the possibility of communication breakdowns and medical errors. This study analyzed after-hours telephone calls to identify opportunities for improved patient safety and quality of care. METHODS AND MATERIALS: Patient calls received outside of business hours between July 1, 2013, and June 30, 2014, at two academic radiation oncology departments were retrospectively reviewed...

INTRODUCTION: Actuality of the problem of patient safety in oncoradiology in Ukraineis grounded. OBJECTIVE: assessment of the safety of patients who performed radiation therapy, and extent of medical and social consequences of erroneous actions of personnel in this area. MATERIAL AND METHODS: The results of international audit TLD (IAEA / WHO) quality during dosimetry procedures cobalt telehamma vehicles in Ukraine are investigated, as well as legal and regulatory framework providing for the safety of radiotherapy care, scientific publications on patient safety...

PURPOSE: High-dose-rate (HDR) brachytherapy is a high-risk procedure with serious errors reported in the medical literature. Our goal was to develop a quality improvement framework for HDR brachytherapy using a multidisciplinary approach. This work describes the time, personnel, and materials involved in implementation as well as staff-reported safety benefits of quality improvement checklists. METHODS AND MATERIALS: Quality improvement was achieved using a department-wide multidisciplinary approach...

PURPOSE: We implemented an electronic event-reporting system to investigate its effect on quality improvement in our department. METHODS: We developed an event-reporting program that launched in October 2012; data analysis was performed in January 2014. Events were logged by the radiation oncology staff and reviewed by our quality and safety committee on a biweekly basis. To measure the efficacy of the new program, and change in safety culture, a Likert-scale survey was administered before, and three months after, implementation of the event-reporting system...