SU-E-T-15: A Home Grown Process Improvement Tracking Tool

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Abstract

Purpose:

To evaluate the use of a web based error tracking system.

Methods:

A web based error tracking system called the PIT (Process Improvement Tracking Tool) was used by all staff members to enter errors found at all parts of the treatment process in four satellite facilities. An error is defined as an action that did not fully comply with policy and procedure. Entries were made in real time by all staff members and require that the user enters the date of the incident, the patient medical record number, the physical location of the site, the process during which the error was found and categorize the incident type.

Results:

Number of errors is approximately proportional to the number of patient treatments. Errors: VBMC 45%, UROC 25%, FROC 13%, PHC 17%. Treatments: VBMC 38%, UROC 32%, FROC 16%, PHC 14%. Staff members making the most mistakes are therapists (36%), dosimetrists (23%) and physicists (15%). Processes where errors were found: physics weekly 25%, therapist weekly 18%, physics second check 15%, physics peer review 6%, therapists check 5%, treatment 5% and various other steps 26%.

Conclusion:

Proportionality of the number of patients treated to the number of errors implies homogeneity across four satellites. Differences between staff member error percentages need to be investigated more thoroughly, but possible explanations are workload and staffing levels. Step in the process where errors are found implies the need for improved processes upstream. Specifically, 5% errors discovered during treatment is considered very high and a specific attempt to reduce it will be undertaken. The vast majority of the errors discovered during treatment were found before the treatment was delivered. Only four were discovered after delivery and none involved significant dose errors. Further work is required to identify the exact procedures within the department that will achieve this goal.

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