Factors Associated With Near-Miss/Safety Incidents in Cancer Radiotherapy


Key Points

  • Factors significantly associated with near-miss or safety incidents were head and neck sites, image-guided intensity-modulated radiotherapy, daily imaging, and tumors staged as T2.
  • The most common root causes of near-miss or safety incidents were documentation, scheduling, and communication errors.

In a single-institution case-control analysis reported in the Journal of Oncology Practice, Judy et al found that complexity of procedure or schedule was a significant factor in near-miss or safety incidents involving cancer patients undergoing radiotherapy.

Study Details

The study involved a retrospective analysis of 200 patients with near-miss or safety incidents between October 2014 and April 2016 and a similar group of 200 control patients matched for time without a near-miss or safety incident at the Department of Radiation Oncology at the University of North Carolina at Chapel Hill. A root cause and incident severity were determined for each near-miss or safety incident.

Risk Factors and Root Causes

On multivariate analysis, near-miss or safety incidents were associated with head and neck sites (odds ratio [OR] = 5.2, P = .01), image-guided intensity-modulated radiotherapy (OR = 3.0, P = .009), daily imaging (OR = 7.0, P < .001), and tumors staged as T2 (OR = 3.3, P = .004). The most common root causes were documentation errors (29%), scheduling errors (29%), communication errors (22%), and technical treatment planning errors (14%).

Of the 200 near-miss or safety incidents, 78 (39%) were near misses that resulted in no change to patient treatment. Of the 122 near-miss or safety incidents affecting treatment, 95 (47.5% of the total) were clinically insignificant and 27 (13.5% of the total) were clinically significant. Communication errors were more likely to result in an event that affected patients compared with documentation errors (OR = 17.0, P < .001) or technical treatment planning errors (OR = 14.0, P < .001). Technical treatment delivery errors were more likely to be associated with a higher incident severity score (P = .005).

The investigators concluded: “Several treatment- and disease-specific factors were found to be associated with a [near-miss or safety incident]. Overall, our results suggest that complexity (eg, head and neck, image-guided intensity-modulated radiotherapy, and daily imaging) might be a contributing factor for a [near-miss or safety incident]. This promotes an idea of developing a more dedicated and robust quality assurance system for complex cases and highlights the importance of a strong reporting system to support a safety culture.”

Gregory D. Judy, MD, of the University of North Carolina Hospitals, Chapel Hill, is the corresponding author of the Journal of Oncology Practice article.

The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.