Consensus recommendations for incident learning database structures in radiation oncology

Abstract

Incident learning is recognized as an invaluable tool for improving the quality and safety of treatments. The consensus recommendations in this report are intended to facilitate the implementation of such systems within individual clinics as well as on broader national and international scales.

A patient safety education program in a medical physics residency

“…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.…”

Patient safety in external beam radiotherapy – Guidelines on risk assessment and analysis of adverse error-events and near misses: Introducing the ACCIRAD project

“…Several studies have reported that a comprehensive QA system-i.e., one that includes assessment of potential errors and learning from such events-improves safety [8,19,21,30]. Given the importance of QA for safety, many scientific and professional organisations, including the ICRP and IAEA [22][23][24][25], as well as the European Authority [10,11,13], have developed guidelines for implementing QA programmes in radiotherapy.…”

“…After more than a century of administering radiation in the treatment of cancer, our technological, theoretical, and practical knowledge has increased to the point that the radiation dose can now be delivered safely and accurately to the target while critical organs are spared [15][16][17][18]. Errors that harm the patient during radiotherapy are very rare, and it is important that we distinguish between adverse events-i.e., those effects that are associated with individual response to a properly administered treatment-and real errors caused by human or machine malfunction [8,[19][20][21]. This differentiation is especially important to avoid increasing public concern about ionising radiation [22][23][24][25].…”

Application of human factors analysis and classification system model to event analysis in radiation oncology

“…1,2 In aviation, systematic event reporting of crashes and near-misses is credited with helping to reduce the risk of fatal accidents by 73%. 3 Similar improvements have been achieved in the nuclear power industry.…”