Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Greenham, Stuart; Manley, Stephen; Turnbull, Kirsty; Hoffmann, Matthew; Fonseca, Amara; Westhuyzen, Justin; Aherne, Noel J; Shakespeare, Thomas P.

doi:10.1016/j.rpor.2018.04.002

Cited by 10 publications

(13 citation statements)

References 31 publications

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“…That year saw the implementation of daily image guided radiation therapy (IGRT) prior to treatment delivery. The impact of IGRT in reducing the severity of errors is reported by Greenham et al [21], as this technology identifies errors prior to treatment delivery rather than after the treatment is delivered, reducing the potential severity of the incident to the patient. This is reflected a decrease in reported SAC scores since 2013.…”

Section: Discussionmentioning

confidence: 98%

Quality management in radiation therapy: A 15 year review of incident reporting in two integrated cancer centres

Smith

Wallis

King

et al. 2020

Technical Innovations & Patient Support in Radiation Oncolo

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a b s t r a c tFifteen years of reported incidents were reviewed to provide insight into the effectiveness of an Incident Learning System (ISL). The actual error rate over the 15 years was 1.3 reported errors per 1000 treatment attendances. Incidents were reviewed using a Mann-Whitney U Test. The average number of incidents per year and the number of incidents per thousand attendances declined over time. Two seven-year periods were considered for analysis and the average for the first period (2005-2011) was 6 reported incidents per 1000 attendances compared to 2 incidents for the later period (2012-2018), p < 0.05. SAC 1 and SAC 2 errors have reduced over time and the reduction could be attributed to the quality assurance aspect of IGRT where the incident is identified prior to treatment delivery rather than after, reducing the severity of any potential incidents. The reasoning behind overall reduction in incident reporting over time is unclear but may be associated to quality and technology initiatives, issues with the ISL itself or a change in the staff reporting culture.Crown

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Section: Discussionmentioning

confidence: 98%

Quality management in radiation therapy: A 15 year review of incident reporting in two integrated cancer centres

Smith

Wallis

King

et al. 2020

Technical Innovations & Patient Support in Radiation Oncolo

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“…Their ratio of near miss to actual incident was 3:1. Greenham et al 14 reported a ratio of approximately 2:1. Holmberg and McClean 44 reported a higher ratio of 14:1.…”

Section: Measuring Safety Culture and Relative Patient Safetymentioning

confidence: 98%

“…The complex nature of radiation oncology requires an incident to be assessed, triaged and managed according to additional taxonomy, such as the degree of dosimetry variance from that prescribed/intended, clinical impact and consequence. General healthcare reporting systems have previously been reported as too broad/blunt for such analysis 11,14 …”

Section: Incident Reporting Terminology and Definitionsmentioning

confidence: 99%

“…General healthcare reporting systems have previously been reported as too broad/blunt for such analysis. 11,14 There are several taxonomy/classification approaches or schemas that have been trialled and published in the literature, 3,11,[15][16][17][18] which provide a more detailed taxonomy and classification system to allow effective assessment, review and learning. These systems look at the classification of incidents according to the pathway of care in radiation oncology from the determination of treatment intent, simulation, planning and dosimetry, through to treatment delivery itself.…”

Section: Incident Reporting Terminology and Definitionsmentioning

confidence: 99%

“…They showed a significant reduction in actual incidents over the 3‐year period, which they attributed to the focus on near miss reporting and the non‐punitive nature of incident review. Greenham et al 14 reported on 5 years of data after the implementation of a clinical incident taxonomy across their three cancer centres, analysing over 700 incident reports. Despite workload increases, they observed that both actual and near miss rates exhibited a downward trend across the reporting period.…”

Section: Does Incident Leaning Reduce Harm or Improve Safety?mentioning

confidence: 99%

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Incident review in radiation oncology

2022

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By its very nature, radiation oncology is a complex, multi-profession dynamic modality of cancer treatment. There are multiple steps with many handovers of work and many opportunities for patient safety to be compromised. Patient safety events can manifest as either actual incidents or near miss/close call events. Reporting and learning from these events is key to quality improvement and patient safety. In this paper, we aim to provide an overview of radiation oncology incident reporting and learning systems. We review the importance of the use of a standardized taxonomy and classification that is specific to radiation oncology workflow, the international systems in current use and the current reporting requirements in Australia and New Zealand. Equally important is the culture that exists alongside the incident learning system. A just culture, where support for reporting exists and there is an adaptive responsive environment to learn and improve patient safety. The incident learning and patient safety system requires constant effort to make it a success. We describe potential measures of safety culture and of relative patient safety and recommend their routine use. We offer this review to stimulate the effort towards a binational voluntary incident learning system, a key pillar for the improvement in patient safety in radiation oncology.

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Evaluating incident learning systems and safety culture in two radiation oncology departments

Adamson

Beldham‐Collins

Sykes

et al. 2021

J of Medical Radiation Sci

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Introduction Radiation oncology patient pathways are complex. This complexity creates risk and potential for error to occur. Comprehensive safety and quality management programmes have been developed alongside the use of incident learning systems (ILSs) to mitigate risks and errors reaching patients. Robust ILSs rely on the safety culture (SC) within a department. The aim of this study was to assess perceptions and understanding of SC and ILSs in two closely linked radiation oncology departments and to use the results to consider possible quality improvement (QI) of department ILSs and SC. Methods A survey to assess perceptions of SC and the currently used ILSs was distributed to radiation oncologists, radiation therapists and radiation oncology medical physicists in the two departments. The responses of 95 staff were evaluated (63% of staff). The findings were used to determine any areas for improvement in SC and local ILSs. Results Differences were shown between the professional cohorts. Barriers to current ILS use were indicated by 67% of respondents. Positive SC was shown in each area assessed: 69% indicated the departments practised a no‐blame culture. Barriers identified in one department prompted a QI project to develop a new reporting system and process, improve departmental learning and modify the overall ILS. Conclusion An understanding of SC and attitudes to ILSs has been established and used to improve ILS reporting, feedback on incidents, departmental learning and the QA program. This can be used for future comparisons as the systems develop.

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Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Cited by 10 publications

References 31 publications

Quality management in radiation therapy: A 15 year review of incident reporting in two integrated cancer centres

Quality management in radiation therapy: A 15 year review of incident reporting in two integrated cancer centres

Incident review in radiation oncology

Evaluating incident learning systems and safety culture in two radiation oncology departments

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