Event (error and near‐miss) reporting and learning system for process improvement in radiation oncology

Abstract

Specially designed electronic event reporting systems in a radiotherapy setting can provide valuable data for process and patient safety improvement and are more effective reporting mechanisms than paper-based systems. Additional work is needed to develop methods that can more effectively utilize reported data for process improvement, including the development of standardized event taxonomy and a classification system for RT.

A patient safety education program in a medical physics residency

“…This aspect of the program benefits from the incident learning system operated by the department 15. This is a high‐volume system focused on near‐miss reports that provides unique opportunities for learning18 and is especially valuable for residents. Incident learning and RCA are particularly important for several reasons: it is one of the pillars of safety and a requirement for practice accreditation,12 it is not well understood or utilized by trainees in general,19 and it is one of the safety topics with the largest gaps in understanding and comfort among residents within radiation oncology 10.…”

“…The needs of the educational program may provide an additional impetus for engaging in such a program. The tools for incident learning in radiotherapy are now well understood and described in the literature18, 27, 28 and specialty‐specific systems are available, such as the RO‐ILS system25 sponsored by ASTRO and AAPM and the Center for Assessment of Radiological Sciences PSO system (cars‐pso.org). Related to this is the need for a strong culture of safety, which is a driving force for quality care.…”

Automatic detection of patient identification and positioning errors in radiation therapy treatment using 3-dimensional setup images

“…4 It is believed that reported clinical error rates may underestimate the true rate, because not all errors are detected in the clinical workflow. 5,6 Radiation therapy error rates may be even higher in developing countries because of a lack of qualified medical physicists or a high staff workload. 7,8 Current methods of preventing positioning and identification errors before radiation therapy treatment primarily involve the direct confirmation of patient-specific identifiers (eg, patient name, treatment site, photo identification) and image guided radiation therapy.…”

Factors associated with event reporting in the pediatric radiation oncology population using an electronic incident reporting system

“…2 In fact, use of systematic incident learning through electronic incident reporting systems has been found to encourage the reporting of incidents, 5 assist with identification of areas for improvement in patient safety, improve event communication, and improve identification of clinical areas that require process and safety improvements. 6,7 Such systems may also empower employees, a key factor that contributes to patient safety. 8 Our center is a large, hospital-based department that treats, on average, more than 200 patients per day, with diverse available treatment modalities.…”