Cause or Effect? Development and Validation of an Event Reporting Database in Radiation Medicine

Kapur, Ajay; Potters, Louis; Bloom, Beatrice; Mallalieu, L Brewster; Adair, N.; Zuvic, P.; Riehl, C.; Montchal, E.

doi:10.1016/j.ijrobp.2011.06.1585

Cited by 1 publication

(1 citation statement)

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“…In this work we reviewed incidents reported in our Aspects-of-Care (AOC) incident-reporting database to extract causes and contributory factors for known failures ( 20 ) and conducted a Failure-Mode-and-Effects-Analysis (FMEA) on our process-map ( 21 ) to predict hypothetical effects relative to patient safety. The rationale for either approach per se is that for every effect there must be a set of causes and for every cause there must be some set of effects ( 22 ).…”

Section: Introductionmentioning

confidence: 99%

Incident Learning and Failure-Mode-and-Effects-Analysis Guided Safety Initiatives in Radiation Medicine

et al. 2013

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By combining incident learning and process failure-mode-and-effects-analysis (FMEA) in a structure-process-outcome framework we have created a risk profile for our radiation medicine practice and implemented evidence-based risk-mitigation initiatives focused on patient safety. Based on reactive reviews of incidents reported in our departmental incident-reporting system and proactive FMEA, high safety-risk procedures in our paperless radiation medicine process and latent risk factors were identified. Six initiatives aimed at the mitigation of associated severity, likelihood-of-occurrence, and detectability risks were implemented. These were the standardization of care pathways and toxicity grading, pre-treatment-planning peer review, a policy to thwart delay-rushed processes, an electronic whiteboard to enhance coordination, and the use of six sigma metrics to monitor operational efficiencies. The effectiveness of these initiatives over a 3-years period was assessed using process and outcome specific metrics within the framework of the department structure. There has been a 47% increase in incident-reporting, with no increase in adverse events. Care pathways have been used with greater than 97% clinical compliance rate. The implementation of peer review prior to treatment-planning and use of the whiteboard have provided opportunities for proactive detection and correction of errors. There has been a twofold drop in the occurrence of high-risk procedural delays. Patient treatment start delays are routinely enforced on cases that would have historically been rushed. Z-scores for high-risk procedures have steadily improved from 1.78 to 2.35. The initiatives resulted in sustained reductions of failure-mode risks as measured by a set of evidence-based metrics over a 3-years period. These augment or incorporate many of the published recommendations for patient safety in radiation medicine by translating them to clinical practice.

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Section: Introductionmentioning

confidence: 99%