title: Quality assurance analysis of a large multicenter practice: does increased complexity of intensity-modulated radiotherapy lead to increased error frequency?
abstract: OBJECTIVE
  Error reduction is an important concern in clinical medicine. Intensity-modulated radiotherapy (IMRT) is an important advancement in radiation oncology that increases the complexity of treatment, potentially increasing the error risk. We studied the frequency and severity of errors in a large multicenter practice to ascertain the impact of quality improvement interventions over time, IMRT, and type of practice.
  
  
  METHODS
  We analyzed prospective data from three academic and 16 community practice sites with 24,775 courses of radiotherapy (9,210 IMRT courses and 15,565 non-IMRT) between January 2006 and December 2009. All IMRT treatment was performed using one centralized dose planning center for all sites.
  
  
  RESULTS
  We prospectively identified various errors or potential errors in 0.14 % vs. 0.40 % of the IMRT vs. non-IMRT courses (13/9,210 vs. 62/15,565, p = 0.0004) and excluding potential errors: 0.03 % for IMRT vs. 0.21% for non-IMRT. We developed the Clinical Radiotherapy Error Severity Scale (CRESS) to classify error severity from 1 to 10, with 1 to 3 for potential or completely correctable errors, 4 to 5 for dose variations <5%, and 6 to 10 for dose variations >5%. Multivariate analyses of CRESS values, severity >4, and any error (including potential) correlated significantly reduced errors with IMRT (p = 0.0001-0.0024) but found no significant difference between the academic and community practice sites and no change in error frequency over time despite implementation of 39 system-wide policy changes by the centralized quality improvement committee.
  
  
  CONCLUSIONS
  Despite the increase in complexity with IMRT compared with conventional radiotherapy, it can be delivered with reduced error frequency.
authors.affiliation: Department of Radiation Oncology, University of Pittsburgh Cancer Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Adam C
authors.initials: AC
authors.lastname: Olson
authors.forename: Rodney E
authors.initials: RE
authors.lastname: Wegner
authors.forename: Carol
authors.initials: C
authors.lastname: Scicutella
authors.forename: Dwight E
authors.initials: DE
authors.lastname: Heron
authors.forename: Joel S
authors.initials: JS
authors.lastname: Greenberger
authors.forename: M Saiful
authors.initials: MS
authors.lastname: Huq
authors.forename: Gregory
authors.initials: G
authors.lastname: Bednarz
authors.forename: John C
authors.initials: JC
authors.lastname: Flickinger
mesh_terms: D006801:Humans; D016015:Logistic Models; D019300:Medical Errors / Q000009:adverse effects / Q000145:classification / Q000706:statistics & numerical data*; D009096:Multi-Institutional Systems / Q000592:standards* / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D011446:Prospective Studies; D011786:Quality Control; D011879:Radiotherapy Dosage; D011880:Radiotherapy Planning, Computer-Assisted / Q000379:methods; D050397:Radiotherapy, Intensity-Modulated / Q000009:adverse effects / Q000379:methods* / Q000592:standards / Q000706:statistics & numerical data; D012720:Severity of Illness Index