Discussion topic:
If you have knowledge of a "medical event" (old term=misadministration) that took place at a present or former place of employment, please briefly describe the event (without disclosing identity of the patient or institution). Also please discuss how the reporting process proceeded (if you were aware of that).
If you don't have first hand experience, explain what would constitute as a "medical event" and how it should be handled.
Does your facility have any incident reporting program in place (i.e. near miss or good catch)? If so, explain what the program is and how it is supposed to work. If not, why don't they?
Discussion post:
At a former place of employment, a medical event that I was made aware of involved a newly hired therapist. In this situation a therapist was hired fresh out of school and was working with some other therapists and a physician was present at the treatment but was doing work on another computer. In this event an arccheck QA plan (with all gantry angles set to zero) was somehow mistakenly imported into a patient’s treatment plan. If I remember correctly the new therapist administered the entire treatment fraction with all gantry angles set to zero and did not notice. The mistake was caught by physics the next day and luckily because it was only the first fraction the plan was able to be recalculated and it was determined this event had little if any effect on the patient’s treatment. I am unsure if this was an event that had to be reported to the state. This is an example of what can happen when therapists let their guard down. The more experienced therapists thought the presence of a physician ensured nothing could go wrong. The new therapist did not question why all treatment angles were the same and assumed any errors with the treatment plan would be caught by physics prior to the treatment. I heard about this story while working in dosimetry and I realized the importance of double checking work and not going too fast. Additionally, a dosimetrist cannot rely on physics or the therapist chart check to catch mistakes.
The NRC gives a lengthy description on reportable medical events however the criteria I’ve heard mentioned the most refers to the 20% rule. The 20% rule states “the total dose delivered differs from the prescribed dose by 20 percent or more” additionally “the total dosage delivered differs from the prescribed dosage by 20 percent or more or falls outside the prescribed dosage range.”1 The NRC gives further in depth guidelines concerning amount of dose and dose to a non-treatment area. Upon closer reading of the NRC guidelines for reporting of medical events I learned that any treatment dose delivered to the wrong patient was a state reportable event. The guideline referring to reportable events specifically states “an administration of a dose or dosage to the wrong individual or human research subject.”1 According to the NRC regulation it seems in cases of incorrectly identified patients treatment the other guidelines that delineate amount of dose or dose delivered to the wrong area do apply and any dose delivered is a reportable event.1
I am not aware of the specific policies of incident reporting at my place of employment. I know that any incidents are reported to management even seemingly small and seemingly inconsequential mistakes. Fortunately, I have not been involved in a medical event so I haven’t witnessed the process personally. I know that my employers encourage us to report any possible events and that the dialogue is very open and employees are not made to fear the consequences of reporting an event.
References
U.S.NRC. Report and notification of a medical event. 35.3045 Subpart M. http://www.nrc.gov/reading-rm/doc-collections/cfr/part035/part035-3045.html. Accessed October 19, 2016.
If you have knowledge of a "medical event" (old term=misadministration) that took place at a present or former place of employment, please briefly describe the event (without disclosing identity of the patient or institution). Also please discuss how the reporting process proceeded (if you were aware of that).
If you don't have first hand experience, explain what would constitute as a "medical event" and how it should be handled.
Does your facility have any incident reporting program in place (i.e. near miss or good catch)? If so, explain what the program is and how it is supposed to work. If not, why don't they?
Discussion post:
At a former place of employment, a medical event that I was made aware of involved a newly hired therapist. In this situation a therapist was hired fresh out of school and was working with some other therapists and a physician was present at the treatment but was doing work on another computer. In this event an arccheck QA plan (with all gantry angles set to zero) was somehow mistakenly imported into a patient’s treatment plan. If I remember correctly the new therapist administered the entire treatment fraction with all gantry angles set to zero and did not notice. The mistake was caught by physics the next day and luckily because it was only the first fraction the plan was able to be recalculated and it was determined this event had little if any effect on the patient’s treatment. I am unsure if this was an event that had to be reported to the state. This is an example of what can happen when therapists let their guard down. The more experienced therapists thought the presence of a physician ensured nothing could go wrong. The new therapist did not question why all treatment angles were the same and assumed any errors with the treatment plan would be caught by physics prior to the treatment. I heard about this story while working in dosimetry and I realized the importance of double checking work and not going too fast. Additionally, a dosimetrist cannot rely on physics or the therapist chart check to catch mistakes.
The NRC gives a lengthy description on reportable medical events however the criteria I’ve heard mentioned the most refers to the 20% rule. The 20% rule states “the total dose delivered differs from the prescribed dose by 20 percent or more” additionally “the total dosage delivered differs from the prescribed dosage by 20 percent or more or falls outside the prescribed dosage range.”1 The NRC gives further in depth guidelines concerning amount of dose and dose to a non-treatment area. Upon closer reading of the NRC guidelines for reporting of medical events I learned that any treatment dose delivered to the wrong patient was a state reportable event. The guideline referring to reportable events specifically states “an administration of a dose or dosage to the wrong individual or human research subject.”1 According to the NRC regulation it seems in cases of incorrectly identified patients treatment the other guidelines that delineate amount of dose or dose delivered to the wrong area do apply and any dose delivered is a reportable event.1
I am not aware of the specific policies of incident reporting at my place of employment. I know that any incidents are reported to management even seemingly small and seemingly inconsequential mistakes. Fortunately, I have not been involved in a medical event so I haven’t witnessed the process personally. I know that my employers encourage us to report any possible events and that the dialogue is very open and employees are not made to fear the consequences of reporting an event.
References
U.S.NRC. Report and notification of a medical event. 35.3045 Subpart M. http://www.nrc.gov/reading-rm/doc-collections/cfr/part035/part035-3045.html. Accessed October 19, 2016.