Key Publications in the Area

Reijnders-Thijssen P, Geerts D, van Elmpt W, Pawlicki T, Wallis A, Coffey M. Prevalence of software alerts in radiotherapy. Technical Innovations & Patient Support in Radiation Oncology. 2020;14:32-35. https://doi.org/10.1016/j.tipsro.2020.04.002

Anderson N, Thompson K, Andrews J, Chesson B, Cray A, Phillips D, Ryan M, Soteriou S, Trainor G, Touma N. Planning for a pandemic: Mitigating risk to radiation therapy service delivery in the COVID‐19 era. Journal of Medical Radiation Sciences. Sep 2020;67(3):243-248. https://doi.org/10.1002/jmrs.406

Franco P, Tesio V, Bertholet J, Gasnier A, Gonzalez Del Portillo E, Spalek M, Bibault JE, Borst G, Van Elmpt W, Thorwarth D, Mullaney L, Røe Redalen K, Dubois L, Chargari C, Perryck S, Heukelom J, Petit S, Lybeer M, Castelli L. Professional quality of life and burnout amongst radiation oncologists: The impact of alexithymia and empathy. Radiother Oncol. 2020 Jun;147:162-168. https://doi.org/10.1016/j.radonc.2020.05.017

Smith S, Wallis A, King O, Moretti D, Vial P, Shafiq J, Barton M, Delaney GP. Quality Management in Radiation Therapy: A 15 year review of incident reporting in two integrated cancer centres. Technical Innovations & Patient Support in Radiation Oncology. 2020; 14:15-20. https://doi.org/10.1016/j.tipsro.2020.02.001

Liszewski B. A prioritization framework for the analysis of near misses in radiation oncology. Tech Innov Patient Support Radiat Oncol. 2020 Jun 12;14:36-42. https://doi.org/10.1016/j.tipsro.2020.04.001

Ralston A, Yuen J. Use of the AAPM safety profile assessment tool to evaluate the change in safety culture after implementing the RABBIT prospective risk management system. Advances in radiation oncology. 2019 Jan ;4(1):150-155. https://doi.org/10.1016/j.adro.2018.08.015

Evans SB, Cain D, Kapur A, Brown D, Pawlicki T. Why Smart Oncology Clinicians do Dumb Things: A Review of Cognitive Bias in Radiation Oncology. Pract Radiat Oncol. 2019 JulAug;9(4):e347-e355. https://doi.org/10.1016/j.prro.2019.03.001

Leonard S, O’Donovan A. Measuring safety culture: Application of the Hospital Survey on Patient Safety Culture to radiation therapy departments worldwide. Pract Radiat Oncol. 2018 Jan-Feb;8(1):e17-e26. https://doi.org/10.1016/j.prro.2017.08.005

Liszewski B, Angers C, Kildea J. Mitigating the Barriers to a Culture of Quality and Safety in Radiation Oncology. Clin Oncol. 2017 Oct;29(10):676-679. https://doi.org/10.1016/j.clon.2017.08.001

Delaney G P, Davies J M. Can the Aviation Industry be Useful in Teaching Oncology about Safety? Clin Oncol. 2017;29:669-675.https://doi.org/10.1016/j.clon.2017.06.007

Pawlicki T, Coffey M, Milosevic M. Incident Learning Systems for radiation oncology: Development and Value at the local, national and international level. Clin Oncol. 2017;29(9):562-567. https://doi.org/10.1016/j.clon.2017.07.009

Huq MS, Fraass BA, Dunscombe PB, Gibbons JP, Jr., Ibbott GS, Mundt AJ, et al. The report of Task Group 100 of the AAPM: Application of risk analysis methods to radiation therapy quality management. Med Phys. 2016;43(7):4209-62. https://doi.org/10.1118/1.4947547

Teixeira FC, de Almeida CE, Saiful Huq M. Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil. Med Phys. 2016;43(1):171-78. https://doi.org/10.1118/1.4938065

Delaney G P. Safety in Radiotherapy mini-series. Clin Oncol. 2017 ;29:553-554. http://dx.doi.org/10.1016/j.clon.2017.06.001

Delaney G P, Papadatos G. Medical Error e the Perspective of the Clinician and the Director of a Department Involved in an Error. Clin Oncol. 2017;29:555-556. http://dx.doi.org/10.1016/j.clon.2017.05.007

Knöös T. Lessons Learnt from Past Incidents and Accidents in Radiation Oncology. Clin Oncology. 2017;29: 557-561. http://dx.doi.org/10.1016/j.clon.2017.06.008

Naessens E D. Medical Error: a Patient’s Perspective. Clin Oncol. 2017;29 : 667-668. http://dx.doi.org/10.1016/j.clon.2017.06.012

Malicki J, Bly R, Bulot M, Godet J-L, Jahnen A, Krengli M, Maingon P, Prieto Martin C, Przybylska K, Skrobała A, Valero M, Jarvinen H. Patient safety in external beam radiotherapy, results of the ACCIRAD project: Current status of proactive risk assessment, reactive analysis of events, and reporting and learning systems in Europe. Radiotherapy and Oncology. 2017; 123(1): 29-36. https://doi.org/10.1016/j.tipsro.2020.04.001

Woodhouse K D, Volz E, Bellerive M, Bergendahl H W, Gabriel P E, Maity A, Hahn S M, Vapiwala N. The implementation and assessment of a quality and safety culture education program in a large radiation oncology department. Pract Radiat Oncol. 2016; 6(4): e127-e134. https://doi.org/10.1016/j.prro.2015.11.011

Milosevic M, Angers C, Liszewski B, Parliament M, Ross S, Brundage M. The Canadian National System for Incident Reporting in Radiation Treatment (NSIR-RT) Taxonomy. Pract Radiat Oncol. 2016; 6(2):334-341. https://doi.org/10.1016/j.prro.2016.01.013

Teixeira F C, de Almeida C E, Saiful Huq M. Failure mode and effects analysis based risk profile assessment for stereotactic radiosurgery programs at three cancer centers in Brazil. Med Phys. 2016;43(1):171-78. https://doi.org/10.1118/1.4938065

Walker G V, Johnson J, Edwards T, Gatilao R A, Hayden S E, Riley B A, Sittig D F, Gillin M, Ibbott G, Buchholz T A, Das P. Factors associated with radiation therapy incidents in a large academic institution. Practical Radiation Oncology. 2015; 5(1): 21-27. https://doi.org/10.1016/j.prro.2014.03.005

Knöös T. QA procedures needed for advanced RT techniques and its impact on treatment outcome.  Journal of Physics: Conference Series 573. 2015; 012001. https://doi.org/10.1088/1742-6596/573/1/012001

Dunscombe P, Brown D, Donaldson H, Greener A, O’Neill M, Sutlief S, et al. Safety Profile Assessment: An online tool to gauge safety-critical performance in radiation oncology. Pract Radiat Oncol. 2015;5(2):127-34. https://doi.org/10.1016/j.prro.2014.10.012

Mayadev J, Dieterich S, Harse R, Lentz S, Mathai M, Boddu S, et al. A failure modes and effects analysis study for gynecologic high-dose- rate brachytherapy. Brachytherapy. 2015;14(6):866-875. https://doi.org/10.1016/j.brachy.2015.06.007

Simons PAM Houben R, Vlayen A, Hellings J, Pijls-Johannesma M, Marneffe W, et al. Does lean management improve patient safety culture? An extensive evaluation of safety culture in a radiotherapy institute. Eur J Oncol Nurs. 2015;19(1):29-37.https://doi.org/10.1016/j.ejon.2014.08.001

Yang F, Cao N, Young L, Howard J, Logan W, Arbuckle T, et al. Validating FMEA output against incident learning data: A study in stereotactic body radiation therapy. Med Phys. 2015;42(6):2777-85. https://doi.org/10.1118/1.4919440

Ford EC, Smith K, Terezakis S, Croog V, Gollamudi S, Gage I, et al. A streamlined failure mode and effects analysis. Med Phys. 2014;41(6):061709. https://doi.org/10.1118/1.4875687

Simons PAM, Houben R, Benders J, Pijls-Johannesma M, Vandijck D, Marneffe W, et al. Does compliance to patient safety tasks improve and sustain when radiotherapy treatment processes are standardized? Eur J Oncol Nurs. 2014;18(5):459-65. https://doi.org/10.1016/j.ejon.2014.05.003

Smith KS, Harris KM, Potters L, Sharma R, Mutic S, Gay HA, et al. Physician attitudes and practices related to voluntary error and near-miss reporting. J Oncol Pract. 2014;10(5):e350-e57. https://doi.org/10.1200/JOP.2013.001353

Williams MV. Improving patient safety in radiotherapy by learning from near misses, incidents and errors. Br J Radiol.2014; 80(953):297-301. https://doi.org/10.1259/bjr/29018029

Perks JR, Stanic S, Stern RL, Henk B, Nelson MS, Harse RD, et al. Failure mode and effect analysis for delivery of lung stereotactic body radiation therapy. International Int J Radiat Oncol Biol Phys. 2012;83(4):1324-29. https://doi.org/10.1016/j.ijrobp.2011.09.019

Ritter T, Balter JM, Lee C, Roberts D, Roberson PL. Audit tool for external beam radiation therapy departments. Practical Radiat Oncol. 2012;2(4):e39-e44.https://doi.org/10.1016/j.prro.2012.03.011

Marks L B, Jackson M, Xie L, Chang S X, Deschesne Burkhardt K, Mazur L, Jones E L, Saponaro P, Dana Lachapelle D, Baynes D C, Adams R D. The challenge of maximizing safety in radiation oncology. Pract Radiat Oncol. Jan-Mar 2011;1(1):2-14. https://doi.org/10.1016/j.prro.2010.10.001

Bissonnette J-P, Medlam G. Trend analysis of radiation therapy incidents over seven years. Radiother & Oncol. 2010;96(1):139-44. https://doi.org/10.1016/j.radonc.2010.05.002

Ford EC, Terezakis S. How Safe Is Safe? Risk in Radiotherapy. Int J Radiat Oncol Biol Phys. 2010;78(2):321-322. https://doi.org/10.1016/j.ijrobp.2010.04.047

Simons PAM, Houben RMA, Backes HH, Pijls RFG, Groothuis S. Compliance to technical guidelines for radiotherapy treatment in relation to patient safety. Int J Qual Health Care. 2010;22(3):187-93. https://doi.org/10.1093/intqhc/mzq020

Rasmussen B and Chu K. TH-C-203-04: Implementation of a “Time Out” Procedure in Radiation Oncology: A Multi-Institution Study over Nine Years Results in a Three-Fold Reduction in Misadministrations. Med. Phys. June 2010; 37(6): 3450-3451. https://doi.org/10.1118/1.3469477

Boadu M, Rehani MM. Unintended exposure in radiotherapy: Identification of prominent causes. Radiother & Oncol. 2009;93(3):609-17. https://doi.org/10.1016/j.radonc.2009.08.044

Ford EC, Gaudette R, Myers L, Vanderver B, Engineer L, Zellars R, et al. Evaluation of Safety in a Radiation Oncology Setting Using Failure Mode and Effects Analysis. Int J Radiat Oncol Biol Phys. 2009;74(3):852-58. https://doi.org/10.1016/j.ijrobp.2008.10.038

Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. An international review of patient safety measures in radiotherapy practice. Radiother & Oncol. 2009;92(1):15-21. https://doi.org/10.1016/j.radonc.2009.03.007

Habraken M M P, Van der Schaaf T W, Leistikow I P and Reijnders-Thijssen P M J. Prospective risk analysis of health care processes: A systematic evaluation of the use of HFMEA™ in Dutch health care. Ergonomics. 2009; 52(7): 809-819. https://doi.org/10.1080/00140130802578563

Rivera AJ, Karsh B-T. Human Factors and Systems Engineering Approach to Patient Safety for Radiotherapy. Int J Radiat Oncol Biol Phys. 2008;71(1, Supplement):S174-S77. http://dx.doi.org/10.1016/j.ijrobp.2007.06.088

Williamson JF, Dunscombe PB, Sharpe MB, Thomadsen BR, Purdy JA, Deye JA. Quality Assurance Needs for Modern Image-Based Radiotherapy: Recommendations From 2007 Interorganizational Symposium on “Quality Assurance of Radiation Therapy: Challenges of Advanced Technology”. Int J Radiat Oncol Biol Phys.2008;71(1, Supplement):S2-S12. https://doi.org/10.1016/j.ijrobp.2007.08.080

Ash D. Lessons from Epinal. Clinical Oncol. 2007;19(8):614-5. https://doi.org/10.1016/j.clon.2007.06.011

Toft B, Mascie-Taylor H. Involuntary automaticity: a work-system induced risk to safe health care. Health Serv Manage Res. 2005;18(4):211-16. https://doi.org/10.1258/095148405774518615

Reason J. Understanding adverse events: human factors. BMJ Qual Saf. 1995;4(2):80-9. https://doi.org/10.1136/qshc.4.2.80

Ash D, Bates T. Report on the clinical effects of inadvertent radiation underdosage in 1045 patients. Clinical Oncol.1994;6(4):214-26. https://doi.org/10.1016/S0936-6555(05)80290-0

ROSEIS Publications

Cunningham J. Radiation Oncology Safety Information System (ROSIS): A Reporting and Learning System for Radiation Oncology. PhD Thesis. Dublin: Trinity College Dublin; 2011. Available from: http://www.tara.tcd.ie/handle/2262/78869 [Accessed 14 May 2021]

Cunningham J, Coffey M, Knöös T, Holmberg O: Radiation Oncology Safety Information System (ROSIS) – Profiles of participants and the first 1074 incident reports. Radiotherapy and Oncology. 2010; 97(3):601-7. https://doi.org/10.1016/j.radonc.2010.10.023

Cunningham, J, Coffey, M, Holmberg, O, Knoos, T. A global standard for incident reporting in radiation therapy using the rosis classification system. (ROSIS = Radiation Oncology Safety Information System). Radiotherapy and Oncology. 2007;84 (1, Supplement):S59. https://doi.org/10.1016/S0167-8140(07)80271-4

Holmberg, O, Cunningham, J, Coffey, M, Knöös, T. ROSIS network. Radiotherapy & Oncology. 2006;81(1, Supplement):S125. https://doi.org/10.1016/S0167-8140(07)80271-4

Cunningham, J, Coffey, M, Holmberg, O, Knöös, T. ROSIS (Radiation Oncology Safety Information System) Recognising risk, enhancing safety. Radiotherapy & Oncology.2004;73(1, Supplement):S220. https://doi.org/10.1016/S0167-8140(04)82361-2

do Carmo Lopes, M. To become an active department in the ROSIS project: process and evaluation. Radiotherapy & Oncology.2004;73(1, Supplement):S220. https://doi.org/10.1016/S0167-8140(04)82362-4

Cunningham, J, Coffey, M, Holmberg, O, Knöös, T. The ROSIS project. Radiotherapy & Oncology.2003;68(1, Supplement):S78. https://doi.org/10.1016/S0167-8140(03)80222-0

Lectures

Legislation

 

ESTRO ROSQ Committee Webinar Series

The series has been designed to provide knowledge and understanding of the issues underpinning safe practice from both the patient and staff perspective.