- Email: [email protected]
Implementation and Analysis of a Prospective Dosimetrist Peer Review
Volume 99 Number 2S Supplement 2017 incorrect data recorded (23%), while the top contributing factor to treatment errors are inattention to details (49%). The survey showed that majority have good personal overall communications with the other staff of the department ranging from 50% (administrators) to 84% (physicians). Also, the results showed a good overall interdisciplinary communication within the department staff ranging from 47% (medical physicists-administrators) to 74% (medical physicists-physicians). About 68% and 58% of the respondents are encouraged and comfortable to report errors, respectively. The top 3 obstacles to reporting errors are: fear of reprimand (42%), poor communication (34%), and lack of reporting system (26%). Although the system does not promote blaming, 16% of the respondents perceived that they have been personally reprimanded due to an error. Conclusion: The adaptation of the ASTRO framework on reporting errors resulted in better identification of areas and factors for improvement Majority of the interpersonal and interdisciplinary communications in the facility is good. Most of the personnel are encouraged and comfortable in reporting treatment errors, although, the top obstacles to error reporting identified need immediate actions in order to promote a better treatment error reporting environment. Author Disclosure: J.S. Flores: None. M. Calaguas: None. L.V. Rodriguez: None. C.C. Yu: None. E. Chiong: None. J.P. Galingana: None. M.A. Tavas: None. J.D. Vales: None. J.T. Canedo: None. J.B. Riparip: None.
3309 Whiteboard Patient Tracking System Improves Radiation Oncology Treatment Planning Workflow N.R. Forster, C. Freese, M. Amlung, B. Kelly, M.A.S. Lamba, and V. Takiar; University of Cincinnati, Cincinnati, OH Purpose/Objective(s): The workflow between CT simulation and treatment delivery requires detailed communication between multiple team members and computer software systems. With increasing clinical demands and multiple facilities, resultant delays may adversely impact patient care. Our goal was to evaluate the clinical impact of a new Whiteboard system to accomplish tasks between CT simulation and treatment delivery. The Whiteboard system allows daily tracking of key steps within the treatment planning workflow, with scheduled periodic automated email reminders for incomplete tasks. We compared the time required for completion of several components of this process, before and after Whiteboard implementation, hypothesizing that Whiteboard usage would decrease the time required to complete the designated task, thereby improving workflow. Materials/Methods: As a historic control, from 2014 and 2016, our dosimetrists tracked completion dates of key components of the radiation oncology workflow. Pending or incomplete patient contours and plan approval requests were sent to physicians via email by the dosimetrist. Three attending physicians were selected who regularly use and update Whiteboard data for their patients and for whom historic data was available. The Whiteboard was implemented in 2016 and tracked patient data in a customizable database. Daily automated email reminders were sent to the physicians regarding incomplete contours or plans awaiting review. Dosimetrists were notified when patients were simulated, contours were complete, and plans were approved. There were 248 patients in the preWhiteboard and 292 in the post-Whiteboard groups, for a total of 540 patients analyzed. The following data were collected for analysis: number of days from CT simulation date to contours approval, simulation date to plan approval, and completed contours to plan approval. Patients with incomplete documentation were excluded. T-tests were used to assess statistical significance. Results: Days from CT simulation to contours approval, simulation to plan approval, and contours to plan approval were assessed. Mean and median intervals are demonstrated in the accompanying table below. In each case, p-values were <0.0001 in favor of Whiteboard implementation. Conclusion: Whiteboard implementation resulted in a significant decrease in time from CT simulation date to contours approval, simulation date to plan approval, and contours to plan approval. When used effectively, an automated Whiteboard system facilitates improved workflow.
Poster Viewing E551 Abstract 3309 Mean (SD) Simulation to Contour Approval (d) Before WB 3.5 After WB 2.1 CT Simulation to Plan Approval (d) Before WB 6.1 After WB 4.4 Contour Approval to Plan Approval (d) Before WB 2.7 After WB 1.6
Median
(2.5) (2.1)
3.0 1.0
(3.4) (2.8)
6.0 5.0
(3.1) (1.9)
1.0 1.0
Author Disclosure: N.R. Forster: None. C. Freese: None. M. Amlung: None. B. Kelly: None. M.A. Lamba: None. V. Takiar: None.
3310 Implementation and Analysis of a Prospective Dosimetrist Peer Review R.D. Foster,1 M. Bright,1 J.H. Heinzerling,2 B.J. Moeller,2 B. Kelly,1 J. Finney,1 and C.J. Hampton1; 1Levine Cancer Institute: Carolinas HealthCare System, Charlotte, NC, 2Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC Purpose/Objective(s): The value and importance of peer review in radiation oncology has been recognized in the field, but published studies focus on physician peer review of contouring and plan goals. The Radiation Oncology Incident Learning System (ROILS) aggregate reports indicate that the most frequently identified workflow step where events occur is treatment planning. To our knowledge, there is no published report describing the implementation and analysis of a dosimetrist peer review process. The purpose of this study is to examine the effectiveness of a dosimetrist peer review implemented within a commercially available record and verify system. Materials/Methods: A checklist/questionnaire was created within our R&V system containing commonly verified plan parameters and tasks. In our clinic, the peer review is first completed by a dosimetrist who did not create the plan and then is double checked by a physicist during the initial plan check. Items that are identified as needing correction are noted first by the peer review dosimetrist and then any remaining items are noted by the physicist. A report is generated that contains all the identified items, which are then categorized and analyzed. We analyzed the items that were caught during the peer review and the items that were caught during the subsequent physicist chart check. Results: For calendar year 2016, dosimetrists made 121 total entries in the peer review questionnaire while physicists made 370 total entries, but each entry could contain more than one item needing correction. While the dosimetrist peer review was effective at identifying incorrect charges, the number of items detected by physicists for other categories outnumber those detected by dosimetrists by a margin of 3 to 1. The table below contains the top 5 most identified items by the dosimetrists and physicists. If billing is removed, then the 5th most detected item by dosimetrists is errors in shifts from the simulation isocenter. Dosimetrists performed peer reviews on 84% of new patient charts for 2016. Reasons for a missing peer review include dosimetrist time off and urgent sim and start patients. Abstract 3310 Rank 1 2 3 4 5
Dosimetrist
Physicist
Billing Setup notes Contouring Prescription Issue Tolerance Table
DRR Issue 2nd MU Calc Issue Tolerance Table Prescription Issue Imaging instructions
Conclusion: We believe this is the first reported implementation and analysis of a formal dosimetrist peer review. While the dosimetrist peer review allowed 75% of the total items through, it was effective at catching certain items, such as billing errors and errors in setup notes. As this is our first analysis of the dosimetrist peer review, this data will serve as our
E552
International Journal of Radiation Oncology Biology Physics
baseline for future comparisons. These results have been shared with the dosimetry staff and additional guidance has been given to improve the detection rate of the dosimetry peer review. We will report updated results at the annual meeting. Author Disclosure: R.D. Foster: None. M. Bright: None. J.H. Heinzerling: None. B.J. Moeller: Independent Contractor; Novant Health. B. Kelly: None. J. Finney: None. C.J. Hampton: Research Grant; Varian Medical Systems.
3312
3311 Developing a Culture of Safety in a Large Academic Radiation Oncology Practice Through Strategic Implementation of Anonymous and Non-anonymous Reporting Systems B.D. Frank,1 J.L. Johnson,2 M.F. McAleer,3 B.M. Beadle,4 T. Edwards,1 H. Bergendahl,5 R. Ghafar,1 and S.M. Hahn6; 1The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, 3University of Texas MD Anderson Cancer Center, Houston, TX, 4Stanford University, Department of Radiation Oncology, Stanford, CA, 5The Bergendahl Institute, LLC, Avon Lake, OH, United States, 6Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX Purpose/Objective(s): Many radiation oncology practices use comprehensive Incident Learning Systems (ILS) to collect data on patient safety events. Despite the vast use of these applications throughout radiation oncology, many practices continue to struggle with the fundamental cultural challenges associated with reporting incidents and safety concerns, including fear of retaliation and intimidation. The purpose of this study is to increase reporting compliance in the practice by introducing a simplified anonymous reporting system (ARS) concurrently with an ILS. Materials/Methods: A robust ILS was developed and deployed in conjunction with a simplified ARS at a single academic institution, and data were collected from submitted reports over a 23-month period from February 2015 to December 2016. Descriptive analyses were used to evaluate reporting patterns. In addition to the reporting tools, the practice leadership routinely promoted reporting of all incidents and near misses, conveyed a zero-tolerance retaliation position and deployed an event reporting policy which defined expectations of reporting errors. Results: A total of 2,275 reports were submitted, 608 anonymously and 1,667 non-anonymously. Over the course of the study, the five month moving average increased from 45.4 reports/month to 138.4 reports/month (mean, 98.9; range, 3 e 162). Overall, the percentage of total reports filed anonymously dropped from 53.8% (49 Anonymous, 42 Non-Anonymous, 91 Total) in Month 1-3 to 9.7% (38 Anonymous, 355 Non-Anonymous, 393 Total) in Month 21-23. It is important to note that during the study, 14 patient safety reports were submitted in the ARS with identifiable reporter characteristics (i.e. name, employee ID). These data were added to the non-anonymous ILS data set. Conclusion: Results suggest a significant cultural change has occurred, and fear of retaliation or intimidation has decreased. Concurrent implementation of both an ARS and a comprehensive ILS with supporting practice changes and infrastructure has decreased overall fear of retaliation and intimidation while increasing patient safety reporting compliance. Author Disclosure: B.D. Frank: None. J.L. Johnson: Honoraria; American College of Radiology - ROPA. Travel Expenses; American College of Radiology - ROPA. M. McAleer: None. B.M. Beadle: Research Grant; NIH. Meeting Chair; American Radium Society. T. Edwards: None. H. Bergendahl: None. R. Ghafar: None. S.M. Hahn: Honoraria; AACR, Academic Institutions, UCSF Cancer Center External Advisory Board, UCSF Radiation Oncology External Advisory Board, UMDNJ Cancer Center. Advisory Board; UMDNJ Cancer Center, University of California, Irvine. Travel Expenses; AACR, Academic Institutions, American Board of Radiology, UCSF Cancer Center External Advisory Boar.
Risk Assessment in Permanent Prostate Brachytherapy Using AAPM TG 100 Methodology W. Gao; Overton Brooks VA Medical Center, Shreveport, LA Purpose/Objective(s): to analyze major risks associated with permanent prostate brachytherapy based on reported medical events and to provide a reasonable estimate of O (Occurrence), S (Severity) and D (lack of detectability) factors for major failure modes (FM) in permanent prostate brachytherapy. Materials/Methods: Between January 1999 and December 2016, 384 patients received prostate seed implants that were reported to NRC as medical events. The majority of those events are excluded from the current study because they were reported solely based on a dose-volume parameter from post-implant dosimetry, e.g. , D90less than the prescribed dose, what could well be the results of prostate expansions before and after the procedures. Incidents related to leaking sources, lost seed or shipment, or aborted procedures due to technical difficulties are also excluded. The present study focuses on the remaining 85 events, as sufficient details were supplied in the reports. For each FM, the Occurrence (O) factor is determined as the frequency of occurrence relative to the most common failure mode(OZ10). The Severity (S) factor of each event, on a scale of 1-10, was given mainly based on the magnitude of dose deviation from the prescribed dose or seed displacement relative to the planned position, or the percentage of source strength implanted outside the target volume. The Severity of each FM is then taken as the average of the severity factors of all medical events in the very category. The Lack of Detectability (D), also on a scale of 1-10, is assigned to each FM based on the nature of the failure, number of patients involved in the same error and author’s experience. The Risk Priority Number or RPN is calculated as RPNZOxSxD. Results: Ten(10) major failure modes (FM) are identified in the study, and they are (from highest to lowest RPN): 1. Significant portion of source strength or activity implanted outside of target volume; 2. Incorrect activity used because of unit error (mCi or air kerma strength) ; 3. Incorrect dose rate constant used in planning system; 4. Incorrect prescription dose used in planning; 5. Shipping error; 6. Incorrect calculation in planning; 7. Wrong plan used in back-to-back implants; 8. Wrong seed package used in back-to back implants; 9. Wrong activity entered in computer planning; and (10) implant rescheduled but old set of seed package used for implant. Conclusion: Incidents reported to regulatory agencies can be used to estimate RPN values for errors in permanent prostate brachytherapy. AAPM TG 100 provides an effective tool for developing a QM program by prioritizing the use of QA resources with priorities given to the most hazardous failures. Author Disclosure: W. Gao: Independent Contractor; SAMP. Honoraria; ACR.
3313 First Report on the Effectivity and Applicability of the German DEGRO/DGK Guideline for Safe Radiation Therapy of CIED-Bearing Patients B. Gauter-Fleckenstein,1 E. Tu¨lu¨men,2 C. Barthel,3 and F. Wenz4; 1 Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany, 2 Department of Cardiology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany, 3Medical School, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany, 4Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany Purpose/Objective(s): Currently, in Germany, patients with implanted cardiac electronic devices (CIED) are treated with radiotherapy (RT) in accordance with the 2015 published German interdisciplinary DEGRO/DGK Guideline. We present the first series of 200 patients treated before (nZ40) and after (nZ160) implementation of the guideline and therefore providing first evidence for the effectivity of recently published recommendations. Materials/Methods: Between 2007 and 04/2011, 40 patients with CIEDs were treated according to AAPM recommendations. As of 05/2011 until
3309 Whiteboard Patient Tracking System Improves Radiation Oncology Treatment Planning Workflow N.R. Forster, C. Freese, M. Amlung, B. Kelly, M.A.S. Lamba, and V. Takiar; University of Cincinnati, Cincinnati, OH Purpose/Objective(s): The workflow between CT simulation and treatment delivery requires detailed communication between multiple team members and computer software systems. With increasing clinical demands and multiple facilities, resultant delays may adversely impact patient care. Our goal was to evaluate the clinical impact of a new Whiteboard system to accomplish tasks between CT simulation and treatment delivery. The Whiteboard system allows daily tracking of key steps within the treatment planning workflow, with scheduled periodic automated email reminders for incomplete tasks. We compared the time required for completion of several components of this process, before and after Whiteboard implementation, hypothesizing that Whiteboard usage would decrease the time required to complete the designated task, thereby improving workflow. Materials/Methods: As a historic control, from 2014 and 2016, our dosimetrists tracked completion dates of key components of the radiation oncology workflow. Pending or incomplete patient contours and plan approval requests were sent to physicians via email by the dosimetrist. Three attending physicians were selected who regularly use and update Whiteboard data for their patients and for whom historic data was available. The Whiteboard was implemented in 2016 and tracked patient data in a customizable database. Daily automated email reminders were sent to the physicians regarding incomplete contours or plans awaiting review. Dosimetrists were notified when patients were simulated, contours were complete, and plans were approved. There were 248 patients in the preWhiteboard and 292 in the post-Whiteboard groups, for a total of 540 patients analyzed. The following data were collected for analysis: number of days from CT simulation date to contours approval, simulation date to plan approval, and completed contours to plan approval. Patients with incomplete documentation were excluded. T-tests were used to assess statistical significance. Results: Days from CT simulation to contours approval, simulation to plan approval, and contours to plan approval were assessed. Mean and median intervals are demonstrated in the accompanying table below. In each case, p-values were <0.0001 in favor of Whiteboard implementation. Conclusion: Whiteboard implementation resulted in a significant decrease in time from CT simulation date to contours approval, simulation date to plan approval, and contours to plan approval. When used effectively, an automated Whiteboard system facilitates improved workflow.
Poster Viewing E551 Abstract 3309 Mean (SD) Simulation to Contour Approval (d) Before WB 3.5 After WB 2.1 CT Simulation to Plan Approval (d) Before WB 6.1 After WB 4.4 Contour Approval to Plan Approval (d) Before WB 2.7 After WB 1.6
Median
(2.5) (2.1)
3.0 1.0
(3.4) (2.8)
6.0 5.0
(3.1) (1.9)
1.0 1.0
Author Disclosure: N.R. Forster: None. C. Freese: None. M. Amlung: None. B. Kelly: None. M.A. Lamba: None. V. Takiar: None.
3310 Implementation and Analysis of a Prospective Dosimetrist Peer Review R.D. Foster,1 M. Bright,1 J.H. Heinzerling,2 B.J. Moeller,2 B. Kelly,1 J. Finney,1 and C.J. Hampton1; 1Levine Cancer Institute: Carolinas HealthCare System, Charlotte, NC, 2Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC Purpose/Objective(s): The value and importance of peer review in radiation oncology has been recognized in the field, but published studies focus on physician peer review of contouring and plan goals. The Radiation Oncology Incident Learning System (ROILS) aggregate reports indicate that the most frequently identified workflow step where events occur is treatment planning. To our knowledge, there is no published report describing the implementation and analysis of a dosimetrist peer review process. The purpose of this study is to examine the effectiveness of a dosimetrist peer review implemented within a commercially available record and verify system. Materials/Methods: A checklist/questionnaire was created within our R&V system containing commonly verified plan parameters and tasks. In our clinic, the peer review is first completed by a dosimetrist who did not create the plan and then is double checked by a physicist during the initial plan check. Items that are identified as needing correction are noted first by the peer review dosimetrist and then any remaining items are noted by the physicist. A report is generated that contains all the identified items, which are then categorized and analyzed. We analyzed the items that were caught during the peer review and the items that were caught during the subsequent physicist chart check. Results: For calendar year 2016, dosimetrists made 121 total entries in the peer review questionnaire while physicists made 370 total entries, but each entry could contain more than one item needing correction. While the dosimetrist peer review was effective at identifying incorrect charges, the number of items detected by physicists for other categories outnumber those detected by dosimetrists by a margin of 3 to 1. The table below contains the top 5 most identified items by the dosimetrists and physicists. If billing is removed, then the 5th most detected item by dosimetrists is errors in shifts from the simulation isocenter. Dosimetrists performed peer reviews on 84% of new patient charts for 2016. Reasons for a missing peer review include dosimetrist time off and urgent sim and start patients. Abstract 3310 Rank 1 2 3 4 5
Dosimetrist
Physicist
Billing Setup notes Contouring Prescription Issue Tolerance Table
DRR Issue 2nd MU Calc Issue Tolerance Table Prescription Issue Imaging instructions
Conclusion: We believe this is the first reported implementation and analysis of a formal dosimetrist peer review. While the dosimetrist peer review allowed 75% of the total items through, it was effective at catching certain items, such as billing errors and errors in setup notes. As this is our first analysis of the dosimetrist peer review, this data will serve as our
E552
International Journal of Radiation Oncology Biology Physics
baseline for future comparisons. These results have been shared with the dosimetry staff and additional guidance has been given to improve the detection rate of the dosimetry peer review. We will report updated results at the annual meeting. Author Disclosure: R.D. Foster: None. M. Bright: None. J.H. Heinzerling: None. B.J. Moeller: Independent Contractor; Novant Health. B. Kelly: None. J. Finney: None. C.J. Hampton: Research Grant; Varian Medical Systems.
3312
3311 Developing a Culture of Safety in a Large Academic Radiation Oncology Practice Through Strategic Implementation of Anonymous and Non-anonymous Reporting Systems B.D. Frank,1 J.L. Johnson,2 M.F. McAleer,3 B.M. Beadle,4 T. Edwards,1 H. Bergendahl,5 R. Ghafar,1 and S.M. Hahn6; 1The University of Texas MD Anderson Cancer Center, Department of Radiation Oncology, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Department of Radiation Physics, Houston, TX, 3University of Texas MD Anderson Cancer Center, Houston, TX, 4Stanford University, Department of Radiation Oncology, Stanford, CA, 5The Bergendahl Institute, LLC, Avon Lake, OH, United States, 6Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX Purpose/Objective(s): Many radiation oncology practices use comprehensive Incident Learning Systems (ILS) to collect data on patient safety events. Despite the vast use of these applications throughout radiation oncology, many practices continue to struggle with the fundamental cultural challenges associated with reporting incidents and safety concerns, including fear of retaliation and intimidation. The purpose of this study is to increase reporting compliance in the practice by introducing a simplified anonymous reporting system (ARS) concurrently with an ILS. Materials/Methods: A robust ILS was developed and deployed in conjunction with a simplified ARS at a single academic institution, and data were collected from submitted reports over a 23-month period from February 2015 to December 2016. Descriptive analyses were used to evaluate reporting patterns. In addition to the reporting tools, the practice leadership routinely promoted reporting of all incidents and near misses, conveyed a zero-tolerance retaliation position and deployed an event reporting policy which defined expectations of reporting errors. Results: A total of 2,275 reports were submitted, 608 anonymously and 1,667 non-anonymously. Over the course of the study, the five month moving average increased from 45.4 reports/month to 138.4 reports/month (mean, 98.9; range, 3 e 162). Overall, the percentage of total reports filed anonymously dropped from 53.8% (49 Anonymous, 42 Non-Anonymous, 91 Total) in Month 1-3 to 9.7% (38 Anonymous, 355 Non-Anonymous, 393 Total) in Month 21-23. It is important to note that during the study, 14 patient safety reports were submitted in the ARS with identifiable reporter characteristics (i.e. name, employee ID). These data were added to the non-anonymous ILS data set. Conclusion: Results suggest a significant cultural change has occurred, and fear of retaliation or intimidation has decreased. Concurrent implementation of both an ARS and a comprehensive ILS with supporting practice changes and infrastructure has decreased overall fear of retaliation and intimidation while increasing patient safety reporting compliance. Author Disclosure: B.D. Frank: None. J.L. Johnson: Honoraria; American College of Radiology - ROPA. Travel Expenses; American College of Radiology - ROPA. M. McAleer: None. B.M. Beadle: Research Grant; NIH. Meeting Chair; American Radium Society. T. Edwards: None. H. Bergendahl: None. R. Ghafar: None. S.M. Hahn: Honoraria; AACR, Academic Institutions, UCSF Cancer Center External Advisory Board, UCSF Radiation Oncology External Advisory Board, UMDNJ Cancer Center. Advisory Board; UMDNJ Cancer Center, University of California, Irvine. Travel Expenses; AACR, Academic Institutions, American Board of Radiology, UCSF Cancer Center External Advisory Boar.
Risk Assessment in Permanent Prostate Brachytherapy Using AAPM TG 100 Methodology W. Gao; Overton Brooks VA Medical Center, Shreveport, LA Purpose/Objective(s): to analyze major risks associated with permanent prostate brachytherapy based on reported medical events and to provide a reasonable estimate of O (Occurrence), S (Severity) and D (lack of detectability) factors for major failure modes (FM) in permanent prostate brachytherapy. Materials/Methods: Between January 1999 and December 2016, 384 patients received prostate seed implants that were reported to NRC as medical events. The majority of those events are excluded from the current study because they were reported solely based on a dose-volume parameter from post-implant dosimetry, e.g. , D90less than the prescribed dose, what could well be the results of prostate expansions before and after the procedures. Incidents related to leaking sources, lost seed or shipment, or aborted procedures due to technical difficulties are also excluded. The present study focuses on the remaining 85 events, as sufficient details were supplied in the reports. For each FM, the Occurrence (O) factor is determined as the frequency of occurrence relative to the most common failure mode(OZ10). The Severity (S) factor of each event, on a scale of 1-10, was given mainly based on the magnitude of dose deviation from the prescribed dose or seed displacement relative to the planned position, or the percentage of source strength implanted outside the target volume. The Severity of each FM is then taken as the average of the severity factors of all medical events in the very category. The Lack of Detectability (D), also on a scale of 1-10, is assigned to each FM based on the nature of the failure, number of patients involved in the same error and author’s experience. The Risk Priority Number or RPN is calculated as RPNZOxSxD. Results: Ten(10) major failure modes (FM) are identified in the study, and they are (from highest to lowest RPN): 1. Significant portion of source strength or activity implanted outside of target volume; 2. Incorrect activity used because of unit error (mCi or air kerma strength) ; 3. Incorrect dose rate constant used in planning system; 4. Incorrect prescription dose used in planning; 5. Shipping error; 6. Incorrect calculation in planning; 7. Wrong plan used in back-to-back implants; 8. Wrong seed package used in back-to back implants; 9. Wrong activity entered in computer planning; and (10) implant rescheduled but old set of seed package used for implant. Conclusion: Incidents reported to regulatory agencies can be used to estimate RPN values for errors in permanent prostate brachytherapy. AAPM TG 100 provides an effective tool for developing a QM program by prioritizing the use of QA resources with priorities given to the most hazardous failures. Author Disclosure: W. Gao: Independent Contractor; SAMP. Honoraria; ACR.
3313 First Report on the Effectivity and Applicability of the German DEGRO/DGK Guideline for Safe Radiation Therapy of CIED-Bearing Patients B. Gauter-Fleckenstein,1 E. Tu¨lu¨men,2 C. Barthel,3 and F. Wenz4; 1 Department of Radiation Oncology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany, 2 Department of Cardiology, Universitaetsmedizin Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany, 3Medical School, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany, 4Department of Radiation Oncology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany Purpose/Objective(s): Currently, in Germany, patients with implanted cardiac electronic devices (CIED) are treated with radiotherapy (RT) in accordance with the 2015 published German interdisciplinary DEGRO/DGK Guideline. We present the first series of 200 patients treated before (nZ40) and after (nZ160) implementation of the guideline and therefore providing first evidence for the effectivity of recently published recommendations. Materials/Methods: Between 2007 and 04/2011, 40 patients with CIEDs were treated according to AAPM recommendations. As of 05/2011 until