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National study to determine the comfort levels of radiation therapists and medical dosimetrists to report errors
Practical Radiation Oncology (2013) 3, e165–e170
www.practicalradonc.org
Original Report
National study to determine the comfort levels of radiation therapists and medical dosimetrists to report errors Jessica A. Church MPH a , Robert D. Adams EdD a,⁎, Laura H. Hendrix MS a , Jordan A. Holmes MD a , Lawrence B. Marks MD a , Ronald C. Chen MD, MPH a, b, c a
Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina c Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina b
Received 12 September 2012; revised 26 October 2012; accepted 3 December 2012
Abstract Purpose: Better understanding of the error reporting culture in radiation oncology treatment facilities, and obstacles to reporting, can provide insight into potential areas for improvement. We conducted a survey of radiation therapists and dosimetrists to examine the error reporting cultures in radiation oncology facilities across the United States and staff comfort in reporting errors. Methods and Materials: In 2011, a national sample of 1500 radiation therapists and 528 dosimetrists was mailed a 27-item survey assessing perceptions regarding communication among staff, comfort in error reporting, and associated obstacles. Survey results were summarized using descriptive statistics, and factors associated with discomfort with error reporting analyzed using multivariate logistic regression. Results: A total of 356 radiation therapists from 47 states (24% response rate) and 190 dosimetrists from 35 states (36% response rate) responded to the survey. Almost all (87% of therapists and 88% of dosimetrists) reported that there is an error reporting system in their treatment facility. Most feel that communication between them and physicians and dosimetrists or physicists (81% and 88% of therapists, and 89% and 88% of dosimetrists, respectively) is good, but only 65% of therapists and 66% of dosimetrists agree that communication with administrators is good. Obstacles to reporting errors included hierarchy within the treatment facility, poor communication, and fear of reprimand. On multivariate analysis, previous personal reprimand for reporting errors (odds ratio, 4.13, P = .001) and reprimand of other therapists and dosimetrists (odds ratio, 2.55, P = .03) were significantly associated with discomfort in error reporting. Conclusions: The majority of therapists and dosimetrists feel communication in their treatment facilities is good and that there are systems in place to report errors. A sizable minority reported experience with reprimand for error reporting that significantly reduced their comfort level with Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2012.12.001) can be found at www.practicalradonc.org. Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Dr, CB #7512, Chapel Hill, NC 27514. E-mail address: [email protected] (R.D. Adams). 1879-8500/$ – see front matter © 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.prro.2012.12.001
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reporting errors. Obstacles identified in this study represent opportunities for future research and potential ways for improvement in radiation oncology treatment facilities. © 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Introduction Radiation oncology has a long-established tradition of embracing interdisciplinary quality assurance steps, both before and during treatment, to maximize patient safety. 1 Dosimetrists play a central role in creating and facilitating a patient's radiation plan, and are often in a position to detect errors in the planning process. Therapists are ultimately responsible for delivering the actual treatment and are often the first to discover and report a treatment error. Thus, both medical dosimetrists and radiation therapists are the critical members of the radiation oncology team who play important roles in preventing and reporting errors. Several recent reports highlighted the potentially severe consequences of errors in radiation treatment, 2-5 prompting initiatives to reduce the risk of errors. One initiative is the creation of a central repository to track and analyze reported errors and “near misses" from centers throughout the United States. 6 However, central to the success of these initiatives is a culture in which staff members are willing to share their concerns about potential errors with their colleagues. In order to better understand this issue, we conducted a survey of a national sample of therapists and dosimetrists to examine the error reporting culture in radiation oncology treatment facilities and factors related to staff comfort in reporting errors.
Methods and materials In 2011, a national random sample of 1500 radiation therapists (representing ~ 10% of therapists in the United States) and 528 medical dosimetrists (representing ~ 20% of dosimetrists in the United States) was obtained from the American Registry of Radiologic Technologists (therapist) and the Medical Dosimetrist Certification Board (dosimetrist) and mailed a 27-item survey (Appendix; available online only at www.practicalradonc.org). This survey, created specifically for this study, includes items assessing the respondent's demographic information, perceptions regarding communication within the treatment facility, as well as comfort in and obstacles to error reporting. A reminder to complete the survey was sent 4 weeks after the initial mailing. Descriptive analyses were performed to assess demographic characteristics and the distribution of survey responses among therapists and dosimetrists separately. Data for all respondents were then pooled, and survey responses “Strongly agree," “Agree," “Neutral," “Dis-
agree," and “Strongly disagree" were collapsed to 2 categories, “Strongly agree/Agree" and “Neutral/Disagree/ Strongly disagree." Discomfort with reporting errors was defined as responding “Neutral," “Disagree," or “Strongly disagree" to the question “I am comfortable reporting errors in the clinic." The Fisher exact test and multivariate logistic regression were used to assess potential factors associated with discomfort in reporting errors.
Results Overall, 356 radiation therapists from 47 states (24% response rate) and 190 medical dosimetrists from 35 states (36% response rate) completed surveys. Three-fourths of responding therapists and two-thirds of responding dosimetrists were female (Table 1). On average, respondents have been in practice for 9 to 12 years, and 60% work in a private practice setting. Almost all respondents (87%-88%) reported that their treatment facility has an error reporting system.
Table 1
Demographic characteristics of respondents
Demographics
Therapists (N = 356) n (%)
Dosimetrists (N = 190) n (%)
Gender Male 85 (25) 59 (32) Female 262 (75) 124 (68) Race Caucasian 306 (88) 170 (91) African American 7 (2) 3 (1) Hispanic 15 (4) 5 (3) Asian/Pacific Islander 20 (6) 9 (5) Age (y) Median (range) 42 (23-66) 42 (25-63) Highest educational level Certificate 52 (15) 19 (10) Associate 121 (34) 43 (23) Bachelor 149 (43) 101 (54) Master or doctoral 27 (8) 24 (13) Years of practice Median (range) 12 (2-40) 9 (1-33) Type of practice Academic 132 (41) 66 (38) Private 192 (59) 107 (62) Is there a system in place for reporting errors in your department? Yes 304 (87) 164 (88) No 45 (13) 22 (12)
Practical Radiation Oncology: October-December 2013
The responses to questions regarding communication and comfort in reporting errors are summarized in Table 2. The majority of respondents (77%-89%) reported good communication (“Strongly agree" or “Agree") with physicians and dosimetrists and physicists, but the proportions reporting good communication with administrators (referring specifically to those at the department level or above) were lower (57%-66%). Overall, 82% of therapists and 91% of dosimetrists answered “Strongly agree" or “Agree" to feeling comfortable reporting errors. Overall, ≈ 4%-20% of respondents noted communication challenges in their clinic by reporting “Strongly disagree" or “Disagree" to 1 or several of the communication items in Table 2. Obstacles noted to the use of the error reporting systems included treatment facility hierarchy (identified by 18% of therapists and 16% of dosimetrists), poor communication (21% of therapists and 19% of dosimetrists), and fear of reprimand (29% and 9%, respectively) (Table 3). Overall, 16% of therapists and 5% of dosimetrists reported that they have been reprimanded or received adverse action for reporting an error; in addition, 29% and 8% reported that additional other staff members have received adverse action. There was no distinction as to whether adverse actions for reporting Table 2
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errors were experiences for first time errors or results of chronic behavior, or whether individuals were reprimanded for reporting the error rather than for some serious infraction. Furthermore, if a mistake was made, most of the therapists felt they were likely to be blamed. Bivariate examinations between factors related to communication and reprimand with whether the respondents feel comfortable reporting errors are summarized in Table 4. Respondents who reported having personally received an adverse action related to reporting an error were significantly less likely to feel comfortable reporting errors (47% vs 90% for those without an adverse action, P b .0001). Seeing other staff members reprimanded had a similar deterrent effect. In addition, good communication with physicians, dosimetrists and physicists, and administrators as well as being encouraged to report errors were all associated with a higher proportion of respondents feeling comfortable with reporting errors. On multivariate analysis, previous personal reprimand (odds ratio [OR], 4.13, P = .001) and reprimand of other therapists and dosimetrists (OR, 2.55, P = .03) were both significantly associated with discomfort in error reporting. Therapists versus dosimetrists were more likely to have discomfort in reporting errors (OR, 2.22, P = .03) Table 5.
Perceptions regarding overall communication and comfort in reporting errors
Survey questions
Strongly disagree n (%)
Disagree n (%)
Neutral n (%)
Agree n (%)
Strongly agree n (%)
The overall communication between me and the physicians in my department is good. Therapists 13 (4) 15 (4) 37 (10) 97 (27) 194 (55) Dosimetrists 5 (3) 9 (5) 8 (4) 41 (21) 127 (67) The overall communication between me and the dosimetrists and physicists in my department is good. Therapists (with dosimetrists) 14 (4) 9 (3) 20 (6) 78 (22) 230 (65) Dosimetrists (with physicists) 7 (4) 3 (1) 13 (7) 30 (16) 137 (72) The overall communication between me and the administrators in my department is good. Therapists 33 (9) 35 (10) 55 (15) 97 (27) 136 (38) Dosimetrists 13 (7) 13 (7) 38 (20) 51 (27) 75 (39) The overall communication between the radiation therapy/medical dosimetry staff and the physicians in my department is good. Therapists 14 (4) 23 (6) 45 (13) 116 (33) 158 (44) Dosimetrists 6 (3) 10 (5) 7 (4) 48 (26) 114 (62) The overall communication between the radiation therapy and medical dosimetry staff and the dosimetrists and physicists in my department is good. Therapists (with dosimetrists) 10 (3) 17 (5) 37 (10) 93 (26) 198 (56) Dosimetrists (with physicists) 5 (3) 6 (3) 10 (5) 33 (18) 131 (71) The overall communication between the radiation therapy and medical dosimetry staff and the administrators in my department is good. Therapists 35 (10) 37 (10) 82 (23) 92 (26) 110 (31) Dosimetrists 13 (7) 13 (7) 36 (20) 55 (30) 67 (36) I am encouraged to report errors in the clinic. Therapists 8 (2) 8 (2) 25 (7) 37 (11) 277 (78) Dosimetrists 6 (3) 1 (1) 11 (6) 16 (8) 156 (82) I am comfortable reporting errors in the clinic. Therapists 18 (5) 18 (5) 29 (8) 53 (15) 236 (67) Dosimetrists 5 (3) 5 (3) 7 (3) 25 (13) 148 (78)
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Table 3 Obstacles to error reporting identified by radiation therapists and dosimetrists Survey questions
Therapists (N = 356) n (%)
Dosimetrists (N = 190) n (%)
Which of the following are major obstacles to reporting errors in your department? Poor communication 74 (21) 28 (19) My personality 12 (3) 7 (5) Fear of reprimand 102 (29) 14 (9) Lack of reporting system 28 (8) 16 (11) Hierarchical structure 63 (18) 24 (16) Other 128 (37) 27 (18) Have you been personally reprimanded or had other adverse action taken for reporting an error? Yes 55 (16) 9 (5) No 299 (84) 181 (95) Have other radiation therapy and medical dosimetry staff at your clinic been reprimanded or had adverse action taken for reporting an error? Yes 103 (29) 16 (8) No 250 (71) 174 (92) Have other staff at your clinic been reprimanded or had other adverse action taken for reporting an error? Yes 64 (18) 38 (20) No 284 (82) 151 (80) If a mistake is made, what percent of the time is a radiation therapist-medical dosimetrist blamed? b 25% 61 (20) 92 (61) 25%-50% 20 (7) 23 (15) 50%-75% 57 (19) 22 (15) N 75% 160 (54) 13 (9)
Discussion Despite a long-standing culture of patient safety and quality assurance, radiation oncology treatment errors do occur and can cause significant patient harm. 2–5 Error reporting plays a central role in preventing treatment errors and is an important tool for maintaining patient safety. A better understanding of the error-reporting culture in radiation oncology treatment facilities, and obstacles to reporting, can provide important insight into potential areas for further improvement. Therefore, the primary goal of this study was to better understand the culture of reporting and safety within private and academic radiation oncology facilities. Through a sample of therapists and dosimetrists across the country, the key findings of this study include the following. (1) The value of error reporting systems is widely recognized in the field of radiation oncology in the United States, as almost all therapists and dosimetrists in our nationwide samples reported that there is an error-reporting system in place at their treatment
facility. Further, the majority of respondents feel that they are encouraged to report errors. (2) Communication is generally good, with 82%-88% of respondents reporting good communication with physicians and 88% reporting good communication with dosimetrists and physicists. Nevertheless, ≈ 4%-20% of respondents noted communication challenges in their clinic. (3) The primary obstacles to error reporting include hierarchical structure of the treatment facility, poor communication, and fear of reprimand. Our findings are novel for radiation oncology, but are consistent with research in other areas of medicine that has shown a link between hierarchical structure and poor communication, and error reporting. A prior study by Lawton et al 7 showed that reporting is limited by the occupational hierarchies of health care, and that staff are reluctant to report their errors to superiors because of the cultural taboos associated with error reporting and the assumption that it could inhibit career development. Further, hierarchical structure can have a powerful influence on how information is communicated. Communication is likely withheld when there are power or status differences between communicators, especially when one is concerned about appearing incompetent or when one perceives that the other, most likely a superior, is not open to communication. 8 Our results demonstrate that in radiation oncology treatment facilities, these situations are likely to occur between therapists and dosimetrists (considered to be “lower" in the organizational hierarchy) and administrators (considered to be “higher"), where only 65% of therapists and 66% of dosimetrists reported good overall communication between themselves and administrators. Ironically, while almost all radiation oncology departments have a system for error reporting, a sizable proportion of the respondents in our study has been personally reprimanded or knows of staff in the department who have been reprimanded for reporting errors. This experience is significantly associated with a dramatic decrease in comfort to report errors; 90%-92% of respondents with no history of personal or other staff reprimand reported feeling comfortable reporting errors, compared with 47%-65% with history of reprimand. This difference persisted on multivariate analysis. Further, we found that the majority of radiation therapists who responded to our survey felt they were primarily blamed when an error is made. We are not aware of other studies in radiation oncology examining factors related to staff comfort in reporting errors. Overall, our results demonstrate the importance of the “culture” within radiation oncology treatment facilities on the potential success of error reporting systems. One potential opportunity for future improvement is to encourage a culture that allows error reporting without fear of reprimand. Such a system is commonplace in the
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Table 4 Bivariate associations between survey responses regarding reprimand and communication with whether the respondents feel comfortable reporting errors Survey questions
Comfortable reporting errors a
Not comfortable reporting errors a
P value
Have you been personally reprimanded or had other adverse action taken for reporting an error? Yes 30 (47) 34 (53) No 430 (90) 48 (10) Have other radiation therapy/medical dosimetry staff at your clinic been reprimanded or had adverse action taken for reporting an error? Yes 71 (60) 48 (40) No 388 (92) 34 (8) Have other staff at your clinic been reprimanded or had other adverse action taken for reporting an error? Yes 66 (65) 36 (35) No 391 (90) 42 (10) The overall communication between me and the physicians in my department is good. SA/A 412 (90) 45 (10) N/D/SD 50 (57) 37 (43) The overall communication between me and the dosimetrists and physicists in my department is good. SA/A 419 (88) 55 (12) N/D/SD 39 (59) 27 (41) The overall communication between me and the administrators in my department is good. SA/A 334 (94) 23 (6) N/D/SD 128 (68) 59 (32) The overall communication between the radiation therapy medical dosimetry staff and the physicians in my department is good. SA/A 394 (91) 40 (9) N/D/SD 63 (60) 42 (40) The overall communication between the radiation therapy and medical dosimetry staff and the dosimetrists and physicists in my department is good. SA/A 404 (89) 49 (11) N/D/SD 52 (61) 33 (39) The overall communication between the radiation therapy and medical dosimetry staff and the administrators in my department is good. SA/A 307 (95) 15 (5) N/D/SD 149 (69) 67 (31) I am encouraged to report errors in the clinic. SA/A 443 (91) 42 (9) N/D/SD 19 (32) 40 (68)
.0001
b .0001
b .0001
b .0001 b .0001
b .0001 b .0001
b .0001
b .0001
b .0001
SA, strongly agree; A, agree; N, neutral; D, disagree; SD, strongly disagree. a From the question “I am comfortable reporting errors in the clinic.” “Comfortable” included responses of “Strongly agree" and “Agree" to this statement, while “Not comfortable” included responses of “Neutral," “Disagree," or “Strongly disagree."
airline and nuclear power industries, where the safety of many depends heavily on workers reporting errors promptly, 9-11 but this has not yet been widely adopted in medicine. 12,13 Wider use of these systems could help move away from the culture in which reporting errors is regarded as a means of potential criticism or punishment for individual staff members. 12 If reporting is perceived as safe, it can improve patient safety. 14 An important limitation of this study is the relatively low response rate, which can represent potential biases in reporting (ie, the characteristics of the therapists and dosimetrists surveyed and also the therapists and dosimetrists who responded may or may not be representative of
the general population of these individuals). Nevertheless, this is a typical response rate for such surveys. Further, this is the first study to examine the issue of patient safety and error reporting from the perspective of therapists and dosimetrists, who are the staff most likely to be involved in preventing and reporting errors in radiation treatment plans and delivery. An important strength of this study is the large sample of respondents representing a broad range of ages, experiences, and educational backgrounds, who work in both academic and private practice settings. In summary, our study confirms the widespread use of error reporting systems in radiation oncology but identifies potential opportunities for continued improvement.
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Table 5 Multivariate logistic regression examining factors associated with discomfort in error reporting a among radiation therapists and dosimetrists Demographics/survey questions OR (95% CI)
P value
Gender Male 1.00 .05 Female 0.53 (0.28-1.01) Race Caucasian 1.00 .60 Other 0.77 (0.30-2.02) Position Dosimetrist 1.00 .03 Therapist 2.22 (1.07-4.61) Highest level of education Certificate or Associate 1.00 .99 Bachelor or higher 1.00 (0.70-1.43) Years of Practice 0 years 1.00 .94 N 0 years 1.00 (0.97-1.04) Type of practice Academic 1.00 .19 Private 1.51 (0.81-2.81) Have you been personally reprimanded or had other adverse action taken for reporting an error? No 1.00 .001 Yes 4.13 (1.80-9.49) Have other radiation therapy-medical dosimetry staff at your clinic been reprimanded or had adverse action taken for reporting an error? No 1.00 .03 Yes 2.55 (1.12-5.80) Have other staff at your clinic been reprimanded or had adverse action taken for reporting an error? No 1.00 .17 Yes 1.77 (0.78-4.03) CI, confidence interval; OR, odds ratio. a From the question “I am comfortable reporting errors in the clinic.” “Discomfort” included responses of “Neutral," “Disagree," or “Strongly disagree."
Specifically, therapists and dosimetrists indicated that a hierarchical structure, poor communication, and fear of reprimand are the 3 important obstacles to error reporting. Future efforts to examine the impact of modifying these factors on reducing treatment errors, as well as the factors that result in reprimand, are needed.
References 1. Yorke E, Gelblum D, Ford E. Patient safety in external beam radiation therapy. AJR Am J Roentgenol. 2011;196:768-772. 2. Bogdanich W. As technology surges, radiation safeguards lag. New York Times (New York edition). January 27, 2010; section A:1. 3. Bogdanich W. Case studies: when medical radiation goes awry. New York Times (New York edition). January 26, 2010; section A:1. 4. Bogdanich W, Rebelo K. A pinpoint beam strays invisibly, harming instead of healing. New York Times (New York edition). December 29, 2010; section A:1. 5. Bogdanich W. Radiation offers new cures and ways to do harm. New York Times (New York edition). January 24, 2010; section A:1. 6. Target safely. Available at: https://www.astro.org/Clinical-Practice/ Patient-Safety/Target-Safely/Index.aspx. Accessed January 5, 2012. 7. Waring J. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med. 2005;60:1927-1935. 8. Sutcliffe K, Lewton E, Rosenthal M. Communication failures: an insidious contributor to medical mishaps. Acad Med. 2004;79: 186-194. 9. Helmreich RL. On error management: Lessons from aviation. BMJ. 2000;320:781-785. 10. Barach P, Small S. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ. 2000; 320:759-763. 11. Williams MV. Improving patient safety in radiotherapy by learning from near misses, incidents and errors Brit. J Radiol. 2007;80:297-301. 12. Lewis GH, Vaithianathan R, Hockey PM, Hirst G, Bagian JP. Counterheroism, common knowledge, and ergonomics: concepts from aviation that could improve patient safety. Milbank Q. 2011;89: 4-38. 13. Terezakis SA, Harris P, DeWeese K, et al. Safety strategies in an academic radiation oncology department and recommendations for action. Jt Comm J Qual Patient Saf. 2011;37:291-299. 14. Leape LL. Reporting of adverse events. N Engl J Med. 2002;347: 1633-1638.
www.practicalradonc.org
Original Report
National study to determine the comfort levels of radiation therapists and medical dosimetrists to report errors Jessica A. Church MPH a , Robert D. Adams EdD a,⁎, Laura H. Hendrix MS a , Jordan A. Holmes MD a , Lawrence B. Marks MD a , Ronald C. Chen MD, MPH a, b, c a
Department of Radiation Oncology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina c Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina b
Received 12 September 2012; revised 26 October 2012; accepted 3 December 2012
Abstract Purpose: Better understanding of the error reporting culture in radiation oncology treatment facilities, and obstacles to reporting, can provide insight into potential areas for improvement. We conducted a survey of radiation therapists and dosimetrists to examine the error reporting cultures in radiation oncology facilities across the United States and staff comfort in reporting errors. Methods and Materials: In 2011, a national sample of 1500 radiation therapists and 528 dosimetrists was mailed a 27-item survey assessing perceptions regarding communication among staff, comfort in error reporting, and associated obstacles. Survey results were summarized using descriptive statistics, and factors associated with discomfort with error reporting analyzed using multivariate logistic regression. Results: A total of 356 radiation therapists from 47 states (24% response rate) and 190 dosimetrists from 35 states (36% response rate) responded to the survey. Almost all (87% of therapists and 88% of dosimetrists) reported that there is an error reporting system in their treatment facility. Most feel that communication between them and physicians and dosimetrists or physicists (81% and 88% of therapists, and 89% and 88% of dosimetrists, respectively) is good, but only 65% of therapists and 66% of dosimetrists agree that communication with administrators is good. Obstacles to reporting errors included hierarchy within the treatment facility, poor communication, and fear of reprimand. On multivariate analysis, previous personal reprimand for reporting errors (odds ratio, 4.13, P = .001) and reprimand of other therapists and dosimetrists (odds ratio, 2.55, P = .03) were significantly associated with discomfort in error reporting. Conclusions: The majority of therapists and dosimetrists feel communication in their treatment facilities is good and that there are systems in place to report errors. A sizable minority reported experience with reprimand for error reporting that significantly reduced their comfort level with Supplementary material for this article (http://dx.doi.org/10.1016/j.prro.2012.12.001) can be found at www.practicalradonc.org. Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, University of North Carolina at Chapel Hill, 101 Manning Dr, CB #7512, Chapel Hill, NC 27514. E-mail address: [email protected] (R.D. Adams). 1879-8500/$ – see front matter © 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.prro.2012.12.001
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reporting errors. Obstacles identified in this study represent opportunities for future research and potential ways for improvement in radiation oncology treatment facilities. © 2013 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved.
Introduction Radiation oncology has a long-established tradition of embracing interdisciplinary quality assurance steps, both before and during treatment, to maximize patient safety. 1 Dosimetrists play a central role in creating and facilitating a patient's radiation plan, and are often in a position to detect errors in the planning process. Therapists are ultimately responsible for delivering the actual treatment and are often the first to discover and report a treatment error. Thus, both medical dosimetrists and radiation therapists are the critical members of the radiation oncology team who play important roles in preventing and reporting errors. Several recent reports highlighted the potentially severe consequences of errors in radiation treatment, 2-5 prompting initiatives to reduce the risk of errors. One initiative is the creation of a central repository to track and analyze reported errors and “near misses" from centers throughout the United States. 6 However, central to the success of these initiatives is a culture in which staff members are willing to share their concerns about potential errors with their colleagues. In order to better understand this issue, we conducted a survey of a national sample of therapists and dosimetrists to examine the error reporting culture in radiation oncology treatment facilities and factors related to staff comfort in reporting errors.
Methods and materials In 2011, a national random sample of 1500 radiation therapists (representing ~ 10% of therapists in the United States) and 528 medical dosimetrists (representing ~ 20% of dosimetrists in the United States) was obtained from the American Registry of Radiologic Technologists (therapist) and the Medical Dosimetrist Certification Board (dosimetrist) and mailed a 27-item survey (Appendix; available online only at www.practicalradonc.org). This survey, created specifically for this study, includes items assessing the respondent's demographic information, perceptions regarding communication within the treatment facility, as well as comfort in and obstacles to error reporting. A reminder to complete the survey was sent 4 weeks after the initial mailing. Descriptive analyses were performed to assess demographic characteristics and the distribution of survey responses among therapists and dosimetrists separately. Data for all respondents were then pooled, and survey responses “Strongly agree," “Agree," “Neutral," “Dis-
agree," and “Strongly disagree" were collapsed to 2 categories, “Strongly agree/Agree" and “Neutral/Disagree/ Strongly disagree." Discomfort with reporting errors was defined as responding “Neutral," “Disagree," or “Strongly disagree" to the question “I am comfortable reporting errors in the clinic." The Fisher exact test and multivariate logistic regression were used to assess potential factors associated with discomfort in reporting errors.
Results Overall, 356 radiation therapists from 47 states (24% response rate) and 190 medical dosimetrists from 35 states (36% response rate) completed surveys. Three-fourths of responding therapists and two-thirds of responding dosimetrists were female (Table 1). On average, respondents have been in practice for 9 to 12 years, and 60% work in a private practice setting. Almost all respondents (87%-88%) reported that their treatment facility has an error reporting system.
Table 1
Demographic characteristics of respondents
Demographics
Therapists (N = 356) n (%)
Dosimetrists (N = 190) n (%)
Gender Male 85 (25) 59 (32) Female 262 (75) 124 (68) Race Caucasian 306 (88) 170 (91) African American 7 (2) 3 (1) Hispanic 15 (4) 5 (3) Asian/Pacific Islander 20 (6) 9 (5) Age (y) Median (range) 42 (23-66) 42 (25-63) Highest educational level Certificate 52 (15) 19 (10) Associate 121 (34) 43 (23) Bachelor 149 (43) 101 (54) Master or doctoral 27 (8) 24 (13) Years of practice Median (range) 12 (2-40) 9 (1-33) Type of practice Academic 132 (41) 66 (38) Private 192 (59) 107 (62) Is there a system in place for reporting errors in your department? Yes 304 (87) 164 (88) No 45 (13) 22 (12)
Practical Radiation Oncology: October-December 2013
The responses to questions regarding communication and comfort in reporting errors are summarized in Table 2. The majority of respondents (77%-89%) reported good communication (“Strongly agree" or “Agree") with physicians and dosimetrists and physicists, but the proportions reporting good communication with administrators (referring specifically to those at the department level or above) were lower (57%-66%). Overall, 82% of therapists and 91% of dosimetrists answered “Strongly agree" or “Agree" to feeling comfortable reporting errors. Overall, ≈ 4%-20% of respondents noted communication challenges in their clinic by reporting “Strongly disagree" or “Disagree" to 1 or several of the communication items in Table 2. Obstacles noted to the use of the error reporting systems included treatment facility hierarchy (identified by 18% of therapists and 16% of dosimetrists), poor communication (21% of therapists and 19% of dosimetrists), and fear of reprimand (29% and 9%, respectively) (Table 3). Overall, 16% of therapists and 5% of dosimetrists reported that they have been reprimanded or received adverse action for reporting an error; in addition, 29% and 8% reported that additional other staff members have received adverse action. There was no distinction as to whether adverse actions for reporting Table 2
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errors were experiences for first time errors or results of chronic behavior, or whether individuals were reprimanded for reporting the error rather than for some serious infraction. Furthermore, if a mistake was made, most of the therapists felt they were likely to be blamed. Bivariate examinations between factors related to communication and reprimand with whether the respondents feel comfortable reporting errors are summarized in Table 4. Respondents who reported having personally received an adverse action related to reporting an error were significantly less likely to feel comfortable reporting errors (47% vs 90% for those without an adverse action, P b .0001). Seeing other staff members reprimanded had a similar deterrent effect. In addition, good communication with physicians, dosimetrists and physicists, and administrators as well as being encouraged to report errors were all associated with a higher proportion of respondents feeling comfortable with reporting errors. On multivariate analysis, previous personal reprimand (odds ratio [OR], 4.13, P = .001) and reprimand of other therapists and dosimetrists (OR, 2.55, P = .03) were both significantly associated with discomfort in error reporting. Therapists versus dosimetrists were more likely to have discomfort in reporting errors (OR, 2.22, P = .03) Table 5.
Perceptions regarding overall communication and comfort in reporting errors
Survey questions
Strongly disagree n (%)
Disagree n (%)
Neutral n (%)
Agree n (%)
Strongly agree n (%)
The overall communication between me and the physicians in my department is good. Therapists 13 (4) 15 (4) 37 (10) 97 (27) 194 (55) Dosimetrists 5 (3) 9 (5) 8 (4) 41 (21) 127 (67) The overall communication between me and the dosimetrists and physicists in my department is good. Therapists (with dosimetrists) 14 (4) 9 (3) 20 (6) 78 (22) 230 (65) Dosimetrists (with physicists) 7 (4) 3 (1) 13 (7) 30 (16) 137 (72) The overall communication between me and the administrators in my department is good. Therapists 33 (9) 35 (10) 55 (15) 97 (27) 136 (38) Dosimetrists 13 (7) 13 (7) 38 (20) 51 (27) 75 (39) The overall communication between the radiation therapy/medical dosimetry staff and the physicians in my department is good. Therapists 14 (4) 23 (6) 45 (13) 116 (33) 158 (44) Dosimetrists 6 (3) 10 (5) 7 (4) 48 (26) 114 (62) The overall communication between the radiation therapy and medical dosimetry staff and the dosimetrists and physicists in my department is good. Therapists (with dosimetrists) 10 (3) 17 (5) 37 (10) 93 (26) 198 (56) Dosimetrists (with physicists) 5 (3) 6 (3) 10 (5) 33 (18) 131 (71) The overall communication between the radiation therapy and medical dosimetry staff and the administrators in my department is good. Therapists 35 (10) 37 (10) 82 (23) 92 (26) 110 (31) Dosimetrists 13 (7) 13 (7) 36 (20) 55 (30) 67 (36) I am encouraged to report errors in the clinic. Therapists 8 (2) 8 (2) 25 (7) 37 (11) 277 (78) Dosimetrists 6 (3) 1 (1) 11 (6) 16 (8) 156 (82) I am comfortable reporting errors in the clinic. Therapists 18 (5) 18 (5) 29 (8) 53 (15) 236 (67) Dosimetrists 5 (3) 5 (3) 7 (3) 25 (13) 148 (78)
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Table 3 Obstacles to error reporting identified by radiation therapists and dosimetrists Survey questions
Therapists (N = 356) n (%)
Dosimetrists (N = 190) n (%)
Which of the following are major obstacles to reporting errors in your department? Poor communication 74 (21) 28 (19) My personality 12 (3) 7 (5) Fear of reprimand 102 (29) 14 (9) Lack of reporting system 28 (8) 16 (11) Hierarchical structure 63 (18) 24 (16) Other 128 (37) 27 (18) Have you been personally reprimanded or had other adverse action taken for reporting an error? Yes 55 (16) 9 (5) No 299 (84) 181 (95) Have other radiation therapy and medical dosimetry staff at your clinic been reprimanded or had adverse action taken for reporting an error? Yes 103 (29) 16 (8) No 250 (71) 174 (92) Have other staff at your clinic been reprimanded or had other adverse action taken for reporting an error? Yes 64 (18) 38 (20) No 284 (82) 151 (80) If a mistake is made, what percent of the time is a radiation therapist-medical dosimetrist blamed? b 25% 61 (20) 92 (61) 25%-50% 20 (7) 23 (15) 50%-75% 57 (19) 22 (15) N 75% 160 (54) 13 (9)
Discussion Despite a long-standing culture of patient safety and quality assurance, radiation oncology treatment errors do occur and can cause significant patient harm. 2–5 Error reporting plays a central role in preventing treatment errors and is an important tool for maintaining patient safety. A better understanding of the error-reporting culture in radiation oncology treatment facilities, and obstacles to reporting, can provide important insight into potential areas for further improvement. Therefore, the primary goal of this study was to better understand the culture of reporting and safety within private and academic radiation oncology facilities. Through a sample of therapists and dosimetrists across the country, the key findings of this study include the following. (1) The value of error reporting systems is widely recognized in the field of radiation oncology in the United States, as almost all therapists and dosimetrists in our nationwide samples reported that there is an error-reporting system in place at their treatment
facility. Further, the majority of respondents feel that they are encouraged to report errors. (2) Communication is generally good, with 82%-88% of respondents reporting good communication with physicians and 88% reporting good communication with dosimetrists and physicists. Nevertheless, ≈ 4%-20% of respondents noted communication challenges in their clinic. (3) The primary obstacles to error reporting include hierarchical structure of the treatment facility, poor communication, and fear of reprimand. Our findings are novel for radiation oncology, but are consistent with research in other areas of medicine that has shown a link between hierarchical structure and poor communication, and error reporting. A prior study by Lawton et al 7 showed that reporting is limited by the occupational hierarchies of health care, and that staff are reluctant to report their errors to superiors because of the cultural taboos associated with error reporting and the assumption that it could inhibit career development. Further, hierarchical structure can have a powerful influence on how information is communicated. Communication is likely withheld when there are power or status differences between communicators, especially when one is concerned about appearing incompetent or when one perceives that the other, most likely a superior, is not open to communication. 8 Our results demonstrate that in radiation oncology treatment facilities, these situations are likely to occur between therapists and dosimetrists (considered to be “lower" in the organizational hierarchy) and administrators (considered to be “higher"), where only 65% of therapists and 66% of dosimetrists reported good overall communication between themselves and administrators. Ironically, while almost all radiation oncology departments have a system for error reporting, a sizable proportion of the respondents in our study has been personally reprimanded or knows of staff in the department who have been reprimanded for reporting errors. This experience is significantly associated with a dramatic decrease in comfort to report errors; 90%-92% of respondents with no history of personal or other staff reprimand reported feeling comfortable reporting errors, compared with 47%-65% with history of reprimand. This difference persisted on multivariate analysis. Further, we found that the majority of radiation therapists who responded to our survey felt they were primarily blamed when an error is made. We are not aware of other studies in radiation oncology examining factors related to staff comfort in reporting errors. Overall, our results demonstrate the importance of the “culture” within radiation oncology treatment facilities on the potential success of error reporting systems. One potential opportunity for future improvement is to encourage a culture that allows error reporting without fear of reprimand. Such a system is commonplace in the
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Table 4 Bivariate associations between survey responses regarding reprimand and communication with whether the respondents feel comfortable reporting errors Survey questions
Comfortable reporting errors a
Not comfortable reporting errors a
P value
Have you been personally reprimanded or had other adverse action taken for reporting an error? Yes 30 (47) 34 (53) No 430 (90) 48 (10) Have other radiation therapy/medical dosimetry staff at your clinic been reprimanded or had adverse action taken for reporting an error? Yes 71 (60) 48 (40) No 388 (92) 34 (8) Have other staff at your clinic been reprimanded or had other adverse action taken for reporting an error? Yes 66 (65) 36 (35) No 391 (90) 42 (10) The overall communication between me and the physicians in my department is good. SA/A 412 (90) 45 (10) N/D/SD 50 (57) 37 (43) The overall communication between me and the dosimetrists and physicists in my department is good. SA/A 419 (88) 55 (12) N/D/SD 39 (59) 27 (41) The overall communication between me and the administrators in my department is good. SA/A 334 (94) 23 (6) N/D/SD 128 (68) 59 (32) The overall communication between the radiation therapy medical dosimetry staff and the physicians in my department is good. SA/A 394 (91) 40 (9) N/D/SD 63 (60) 42 (40) The overall communication between the radiation therapy and medical dosimetry staff and the dosimetrists and physicists in my department is good. SA/A 404 (89) 49 (11) N/D/SD 52 (61) 33 (39) The overall communication between the radiation therapy and medical dosimetry staff and the administrators in my department is good. SA/A 307 (95) 15 (5) N/D/SD 149 (69) 67 (31) I am encouraged to report errors in the clinic. SA/A 443 (91) 42 (9) N/D/SD 19 (32) 40 (68)
.0001
b .0001
b .0001
b .0001 b .0001
b .0001 b .0001
b .0001
b .0001
b .0001
SA, strongly agree; A, agree; N, neutral; D, disagree; SD, strongly disagree. a From the question “I am comfortable reporting errors in the clinic.” “Comfortable” included responses of “Strongly agree" and “Agree" to this statement, while “Not comfortable” included responses of “Neutral," “Disagree," or “Strongly disagree."
airline and nuclear power industries, where the safety of many depends heavily on workers reporting errors promptly, 9-11 but this has not yet been widely adopted in medicine. 12,13 Wider use of these systems could help move away from the culture in which reporting errors is regarded as a means of potential criticism or punishment for individual staff members. 12 If reporting is perceived as safe, it can improve patient safety. 14 An important limitation of this study is the relatively low response rate, which can represent potential biases in reporting (ie, the characteristics of the therapists and dosimetrists surveyed and also the therapists and dosimetrists who responded may or may not be representative of
the general population of these individuals). Nevertheless, this is a typical response rate for such surveys. Further, this is the first study to examine the issue of patient safety and error reporting from the perspective of therapists and dosimetrists, who are the staff most likely to be involved in preventing and reporting errors in radiation treatment plans and delivery. An important strength of this study is the large sample of respondents representing a broad range of ages, experiences, and educational backgrounds, who work in both academic and private practice settings. In summary, our study confirms the widespread use of error reporting systems in radiation oncology but identifies potential opportunities for continued improvement.
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Table 5 Multivariate logistic regression examining factors associated with discomfort in error reporting a among radiation therapists and dosimetrists Demographics/survey questions OR (95% CI)
P value
Gender Male 1.00 .05 Female 0.53 (0.28-1.01) Race Caucasian 1.00 .60 Other 0.77 (0.30-2.02) Position Dosimetrist 1.00 .03 Therapist 2.22 (1.07-4.61) Highest level of education Certificate or Associate 1.00 .99 Bachelor or higher 1.00 (0.70-1.43) Years of Practice 0 years 1.00 .94 N 0 years 1.00 (0.97-1.04) Type of practice Academic 1.00 .19 Private 1.51 (0.81-2.81) Have you been personally reprimanded or had other adverse action taken for reporting an error? No 1.00 .001 Yes 4.13 (1.80-9.49) Have other radiation therapy-medical dosimetry staff at your clinic been reprimanded or had adverse action taken for reporting an error? No 1.00 .03 Yes 2.55 (1.12-5.80) Have other staff at your clinic been reprimanded or had adverse action taken for reporting an error? No 1.00 .17 Yes 1.77 (0.78-4.03) CI, confidence interval; OR, odds ratio. a From the question “I am comfortable reporting errors in the clinic.” “Discomfort” included responses of “Neutral," “Disagree," or “Strongly disagree."
Specifically, therapists and dosimetrists indicated that a hierarchical structure, poor communication, and fear of reprimand are the 3 important obstacles to error reporting. Future efforts to examine the impact of modifying these factors on reducing treatment errors, as well as the factors that result in reprimand, are needed.
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