Quality Improvement in External Radiation Therapy Using a Departmental Incident Reporting System and Multidisciplinary Team Efforts

Abstract

Purpose: Incidents in radiation therapy occur due to the complex process, non-automated procedures, and miscommunication. We performed a prospective study to reduce the incidence rate during 4 years of external radiation therapy using incident-reporting system with multidisciplinary team (MDT) efforts. Methods:Incidents from May 2009 to April 2013 were recorded, blame-free and voluntarily. The incidents involved errors which were unintended, whether they caused patient harm or not. Cause analysis of the incidents and interventions were performed through an MDT meeting in which all staff participated, including radiation oncologists, medical physicists, nurses, and radiation technologists. Our interventions included continuous feedback and improvements with minimized unnecessary stress. Results:In total, 49 actual incidents among 2,350 radiation therapy courses were noted during the 4 years. The actual incidents occurred most frequently during treatment planning (74%, 36/49), followed by treatment delivery (20%, 10/49). Of the 49 actual incidents, 59%, 16%, 12%, 8%, 2%, 2% incidents were caused by failure to follow procedures or policies, incomplete knowledge, miscommunication, operation errors, work environment, and incorrect supervision, respectively. The actual incident rates, based on the number of treatment courses, were 4%, 2%, 1%, and 1% in the first, second, third, and fourth years, respectively. We found a significant decrease in the actual incident rate during the third and fourth years compared with the first year (p<0.01). Conclusions:The frequency of incidents during radiation therapy was reduced using a voluntary incident reporting system and the efforts of a MDT.

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

“…Our experience had no such transition period, with electronic reporting established well before the study period. Ota et al 21 reported on 1063 incident reports with an average incident rate per 100 RT courses of 1.7 ± 0.4; when excluding near misses, their rate fell to 1.4 ± 0.3. The relatively small difference between the two rates could indicate a poorer reporting culture around near-miss events.…”

“…Overall incident rates were collected over five years and benchmarked against published data. 21 Incident rates were based on the number of treatment courses each year. Incident data from 2011 was compared with 2015; in addition, the first two years were compared with the last two years.…”