Rate of Radiation Therapy Events in a Large Academic Institution

Purpose: The goals of this study were to determine the rate of radiation therapy patient events at a large academic institution and to evaluate temporal trends in this rate using statistical process control tools. Methods: An incident reporting system was used to prospectively collect information on radiation therapy patient events and near misses or good catches, using paper-based reports through December 2010 and an online electronic reporting system from January 2011 onward. Patient events were classified into 3 categories on the basis of their severity. The rate of these events from January 2008 to December 2011 was determined. p charts were used to evaluate trends over time. Results: There were 188 radiation therapy events in the 4-year period, of which 38 were level I or II (more severe) events and 150 were level III (less severe) events. During this 4-year period, a total of 28,488 new patients were treated, and a total of 618,461 radiation fractions were delivered. The rate of radiation therapy events was 0.66% per patient and 0.03% per radiation fraction. There were 358 near misses and good catches in the 4-year period. The p charts indicated that there were no significant changes in the rate of radiation therapy events over time. Conclusions: The rate of radiation therapy events was very low and remained stable over a 4-year period. In the absence of a national reporting system, single-institution reports can provide valuable information on radiotherapy patient event rates and can augment quality improvement efforts.