Literature Review of Vaginal Stenosis and Dilator Use in Radiation Oncology

PurposeGuidelines for the care of women undergoing pelvic radiation therapy (RT) recommend vaginal dilator therapy (VDT) to prevent radiation-induced vaginal stenosis (VS); however, no standard protocol exists. This review seeks to update our current state of knowledge concerning VS and VDT in radiation oncology.Methods and MaterialsA comprehensive literature review (1972-2017) was conducted using search terms “vaginal stenosis,” “radiation,” and “vaginal dilator.” Information was organized by key concepts including VS definition, time course, pathophysiology, risk factors, and interventions.ResultsVS is a well-described consequence of pelvic RT, with early manifestations and late changes evolving over several years. Strong risk factors for VS include RT dose and volume of vagina irradiated. Resultant vaginal changes can interfere with sexual function and correlational studies support the use of preventive VDT. The complexity of factors that drive noncompliance with VDT is well recognized. There are no prospective data to guide optimal duration of VDT, and the consistency with which radiation oncologists monitor VS and manage its consequences is unknown.ConclusionsThis review provides information concerning VS definition, pathophysiology, and risk factors and identifies domains of VDT practice that are understudied. Prospective efforts to monitor and measure outcomes of patients who are prescribed VDT are needed to guide practice.     

Human Error Bowtie Analysis to Enhance Patient Safety in Radiation Oncology

PurposeEnsuring safety within RT is of paramount importance. To further support and augment patient safety efforts, the purpose of this research was to test and refine a robust methodology for analyzing human errors that defeat individual controls within RT quality assurance (QA) programs.MethodsThe method proposed for performing Bowtie Analysis (BTA) was based on training and recommendations from practitioners in the field of Human Factors and Ergonomics practice. Multidisciplinary meetings to iteratively develop BTA focused on incorrect site setup instructions was conducted.ResultsFrom November 2015 to February 2017, we had 12 reported incidents related to site setup notes that could have led to site setup errors. Based on this data, we conducted five BTA analyses related to incorrect site setup instructions. None of the individual controls within our QA program designed to check for potential errors with site setup instructions met the level of robustness to be classified as key safeguards or barriers.ConclusionsThe relatively low number of incidents causing patient harm has led us to typically assume that we have sufficient and effective controls in place to prevent serious human errors from leading to severe patient consequences. Based on our BTA, we question how well we truly understand the details of our individual controls. To meet the level of safety achieved by high reliability organizations (HROs), we need to better ensure that our controls are as reliable and robust as we assume.     

Why Smart Oncology Clinicians do Dumb Things: A Review of Cognitive Bias in Radiation Oncology

This review will discuss the (perhaps biased) way in which smart oncologists think, biases they can identify, and potential strategies to minimize the impact of bias. It is critical to understand cognitive bias as a significant risk (recognized by the Joint Commission) associated with patient safety, and cognitive bias has been implicated in major radiotherapy incidents. The way in which we think are reviewed, covering both System 1 and system 2 processes of thinking, as well as behavioral economics concepts (prospect theory, expected utility theory). Predisposing factors to cognitive error are explained, with exploration of the groupings of person factors, patient factors, and system factors which can influence the quality of our decision-making. Other factors found to influence decision making are also discussed (rudeness, repeated decision making, hunger, personal attitudes). The review goes on to discuss cognitive bias in the clinic and in workplace interactions (including recruitment), with practical examples provided of each bias. Finally, the review covers strategies to combat cognitive bias, including summarize aloud, crowd wisdom, prospective hindsight, and joint evaluation. More definitive ways to mitigate bias are desirable.