Mitigating the Barriers to a Culture of Quality and Safety in Radiation Oncology

Liszewski, Brian; Angers, Crystal; Kildea, J.

doi:10.1016/j.clon.2017.08.001

Cited by 4 publications

(5 citation statements)

References 11 publications

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“…ILS success is related to appropriate resources and utilisation, partnered with staff understanding and confidence that the SC is just and equitable. 25 Respondents' perceptions of SC and learning were stronger towards positive SC than negative, for example two-thirds felt encouraged to report and comfortable reporting. A no-blame culture was perceived by most respondents, with 73% not having witnessed or received adverse action.…”

Section: Discussionmentioning

confidence: 97%

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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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Section: Discussionmentioning

confidence: 97%

“…noted that electronic ILSs, customised to radiation oncology, reduce reporting barriers. ILS success is related to appropriate resources and utilisation, partnered with staff understanding and confidence that the SC is just and equitable 25 …”

Section: Discussionmentioning

confidence: 99%

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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“…This relies on the system being designed such that investigations are conducted in a nonpunitive way, using a just-culture approach. 7,8 One indicator of a strong safety culture is the number of incidents submitted to the ILS, with a higher number showing more individuals engaged and willing to bring forward potential events. 9,10 In March 2020, the COVID-19 pandemic forced rapid changes to healthcare workflows throughout the world.…”

Section: Introductionmentioning

confidence: 99%

“…The success of an ILS within that context requires that individuals recognize the importance of the system and feel comfortable reporting errors and near misses. This relies on the system being designed such that investigations are conducted in a nonpunitive way, using a just‐culture approach 7,8 . One indicator of a strong safety culture is the number of incidents submitted to the ILS, with a higher number showing more individuals engaged and willing to bring forward potential events 9,10 …”

Section: Introductionmentioning

confidence: 99%

The impact of COVID‐19 workflow changes on radiation oncology incident reporting

Volpini

Lekx‐Toniolo

Mahon

et al. 2022

J Applied Clin Med Phys

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Background The Ottawa Hospital's Radiation Oncology program maintains the Incident Learning System (ILS)—a quality assurance program that consists of report submissions of errors and near misses arising from all major domains of radiation. In March 2020, the department adopted workflow changes to optimize patient and provider safety during the COVID‐19 pandemic. Purpose In this study, we analyzed the number and type of ILS submissions pre‐ and postpandemic precautions to assess the impact of COVID‐19‐related workflow changes. Methods ILS data was collected over six one‐year time periods between March 2016 and March 2021. For all time periods, the number of ILS submissions were counted. Each ILS submission was analyzed for the specific treatment domain from which it arose and its root cause, explaining the impetus for the error or near miss. Results Since the onset of COVID‐19‐related workflow changes, the total number of ILS submissions have reduced by approximately 25%. Similarly, there were 30% fewer ILS submissions per number of treatment courses compared to prepandemic data. There was also an increase in the proportion of “treatment planning” ILS submissions and a 50% reduction in the proportion of “decision to treat” ILS submissions compared to previous years. Root cause analysis revealed there were more incidents attributable to “poor, incomplete, or unclear documentation” during the pandemic year. Conclusions COVID‐19 workflow changes were associated with fewer ILS submissions, but a relative increase in submissions stemming from poor documentation and communication. It is imperative to analyze ILS submission data, particularly in a changing work environment, as it highlights the potential and realized mistakes that impact patient and staff safety.

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“…In the first of two Clinical Oncology issues presenting the Safety in Radiotherapy mini-series of articles, my colleague, George Papadatos and I describe an incident early in our careers as radiation oncologists that has strongly influenced how we, and our department, deal with incidents [1]; Knoos [2] describes a number of radiation incidents that led to significant patient harm and what we might learn from these incidents; and Coffey et al [3] describe safety reporting systems that have been developed and how they aid safety. In the next issue, Naessens [4] describes the patient's experience of medical error; Jan Davies, an international expert in aviation science as well as anaesthesiology, together with my assistance, use methods used in the aviation industry to provide advice to the radiation oncology community on how radiation oncology might learn more from current processes in aviation [5], and Liszewski et al [6] describe how a safety reporting culture might be implemented into a department that does not have one.…”

mentioning

confidence: 99%

Safety in Radiotherapy mini-series

Delaney

2017

Clinical Oncology

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Mitigating the Barriers to a Culture of Quality and Safety in Radiation Oncology

Cited by 4 publications

References 11 publications

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

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

The impact of COVID‐19 workflow changes on radiation oncology incident reporting

Safety in Radiotherapy mini-series

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