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Time for Chart Rounds: Patient Safety and Peer Review in Radiation Oncology

December 14, 2021

The December 2021 #radonc #JC begins Saturday, December 18th 8AM CST and continues through Sunday, December 19th to the Live Hour on Sunday at 1PM CST.

One of the immeasurable joys of radiation oncology as a field is the requirement for teamwork; no individual can complete the process of treating a patient from start to finish alone. With a multitude of tasks to execute – performed synchronously by a team of healthcare professionals – comes a compounding risk of events that compromise patient safety. As medical errors are notorious for serving as a leading cause of death across all disciplines of healthcare, patient safety is of substantial interest within radiation oncology, with quality assurance (QA) being performed rigorously by medical physicist colleagues and advised extensively (e.g. with iterations of American Association of Physicists in Medicine (AAPM) Task Group (TG) reports as well as the ASTRO Patient Safety White Papers [1].

While medical errors will never be entirely extinguished due to the fallible nature of humanity, they can be substantially reduced by championing a culture of safety. For all stakeholders of our health systems, #PatientsIncluded, quality improvement (QI) and patient safety are a priority. Over decades, we have accumulated exponentially increasing knowledge guided by clinical experience and scientific investigation. However, in well-developed countries, we do not always achieve outcomes that are commensurate with our expenditure in effort, with wide variations note among different patient demographics.

In developing countries, having limitations in resources means that radiotherapy may not be available at all. As organizations and governments pay more attention to tenets like quality and safety in healthcare decisions [2-4], it’s critical for us to understand the data needed ensure these tenets are upheld.

Peer review in radiation oncology (colloquially referred to as “chart rounds”) exemplifies a unique aspect of QA and quality improvement (QI) within the field that exists nearly ubiquitously across radiation oncology departments. Within the last couple decades, congruent with corresponding evolutions in treatment planning techniques and technology, efforts have been undertaken to improve upon our peer review process. A 2015 study by Cox et al. reported that as many as 36% of treatment plans required modification prior to initiation of treatment planning [5]; subsequent improvements on the peer review process at the institution led to the inception of daily “Smart Rounds” with an associated grading system [6]. Other institutions followed suit with transitioning to prospective peer review; Surucu et al. reported on the development of contouring and planning rounds (CPR) with creation of “care paths” to guide planning urgency [7]. Of interest, Walburn et al. went one step further and studied clinician behavior and compliance with peer review recommendations to analyze covariates associated with adoption of suggested changes [8].

With all of these changes to the peer review process comes the fundamental question: Is chart rounds an effective form of peer review to begin with?

A study by Talcott et al. endeavors to shed some light on this matter [9], and it is this paper we are thrilled to discuss for this month’s journal club:

Talcott WJ et al. A Blinded, Prospective Study of Error Detection During Physician Chart Rounds in Radiation Oncology. Pract Radiat Oncol. 2020;10(5):312-320.

In this blinded, prospective study, investigators portrayed problematic plans taken from the Radiation Oncology Incident Learning System (RO-ILS) at chart rounds. Of 20 faulty plans, the reported detection rate was 55% (11 of 20), with higher detection rates noted for cases presented earlier in chart rounds (within the first 30 minutes) than later (within the last 30 minutes) (OR 0.11; p=.037). The study overall suggests a need for improvement in the chart rounds process itself.

We are pleased to be joined in discussion of this fascinating topic by study authors Dr. Wesley Talcott (@TalcottMd) and Dr. Sue Evans (@SueEvansMDMPH) as well as lead discussants Dr. Bhisham Chera (@BhishamCheraMD), Dr. Abhishek Solanki (@abhiAsolanki), and Dr. Brett Cox (@brettcoxmd).

Guiding Topics for this month’s #radonc #JC:

T1. Background: How does your institution perform chart rounds and peer review? Who attends chart rounds? Which other means of quality assurance (QA) and quality improvement (QI) and are undertaken in your department to promote patient safety?

T2. Methods: How was the Radiation Oncology Incident Learning System (RO-ILS) navigated for selection of faulty treatment plans? What was the type and frequency of plan errors (e.g. wrong site, inadequate coverage) used? What measures were taken to ensure that non-investigators remained blinded to study procedures?

T3. Results & Discussion: What were the severity and detectability scores associated with the plans, and what was the rate of error detection for each error type? Which covariates/factors were associated with decreased likelihood of error detection, if any? Were the findings of this study expected?

T4. #PatientsIncluded:  What do patients think of quality assurance and improvement processes in radiation oncology? Is this the same for policymakers?

T4. Conclusion & Next Steps: How may we improve upon chart rounds to increase likelihood of detecting errors? What are the relative merits and drawbacks of prospective versus retrospective peer review?  What should constitute peer review? How can this support a quality and safety culture?
Some tips to participate:

  • Guidelines on how to sign up & participate
  • Disclaimer for ways to keep #RadOnc #JC rewarding and professional. If you’re not ready, just lurk & tune in to the conversation.


[1] Marks LB, Adams RD, Pawlicki T, et al. Enhancing the role of case-oriented peer review to improve quality and safety in radiation oncology: Executive summary. Pract Radiat Oncol. 2013;3(3):149-156.

[2] Westervelt A. IAEA Launches Training Material to Strengthen Safety Culture in Medicine. 2021. Accessed at on 12 December 2021.

[3] Peer Review Quality Assurance for Radiation Therapy. Cancer Quality Council of Ontario. 2021. Accessed at on 12 December 2021.

[4] American Society of Radiation Oncology. Safety is No Accident. 2019. Accessed at on 12 December 2021.

[5] Cox BW, Kapur A, Sharma A. Prospective contouring rounds: A novel, high-impact tool for optimizing quality assurance. Pract Radiat Oncol. 2015;5:e431–e436.

[6] Cox BW, Teckie S, Kapur A, Chou H, Potters L. Prospective peer review in radiation therapy treatment planning: long-term results from a longitudinal study. Pract Radiat Oncol 2020;10:e199-e206.

[7] Surucu M, Bajaj A, Roeske JC, et al. The Impact of Transitioning to Prospective Contouring and Planning Rounds as Peer Review. Adv Radiat Oncol. 2019;4(3):532-540.

[8] Walburn T, Wang K, Sud S, et al. A Prospective Analysis of Radiation Oncologist Compliance with Early Peer Review Recommendations. Int J Radiat Biol Phys. 2019; 104(3):494-500.

[9] Talcott WJ, Lincoln H, Kelly JR, et al. A Blinded, Prospective Study of Error Detection During Physician Chart Rounds in Radiation Oncology. Pract Radiat Oncol. 2020;10(5):312-320.

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