A nationwide investigation of radiation therapy event reporting-and-learning systems: Can standards be improved?

A Longitudinal Evaluation of Computed Tomography Radiation Incidents Within a Multisite NHS Trust

“…19 The person approach can prevent a review of the system and may also dissuade staff from speaking out, inciting a culture of fear. 20 Contrary to this, in the most recent incident data within this study, documented lessons learned had been shared using a variety of communication channels. Dissemination is important because it is the "response from incidents that leads to change," 21 and critically, the CQC can request this evidence during review of incidents or site visits.…”

“…Although this attempts to make individuals less fallible, the system approach encompasses improvement focused on the whole team and workplace 19 . The person approach can prevent a review of the system and may also dissuade staff from speaking out, inciting a culture of fear 20 . Contrary to this, in the most recent incident data within this study, documented lessons learned had been shared using a variety of communication channels.…”

“…The highest number of incidents was reported on Mondays and Wednesdays, although there were records from all days of the week (range, [12][13][14][15][16][17][18][19][20][21][22][23][24]. A logistic regression model was applied to the data, but there was no statistical difference between days.…”