Improving Incident Reporting in a Hospital-Based Radiation Oncology Department: The Impact of a Customized Crew Resource Training and Event Reporting Intervention

Abstract

Background Radiation oncology (RO) is a high-risk environment with an increased potential for error due to the complex automated and manual interactions between heterogeneous teams and advanced technologies. Errors involving procedural deviations­­ can adversely impact patient morbidity and mortality. Under-reporting of errors is common in healthcare for reasons such as fear of retribution, liability, embarrassment, etc. Incident reporting is a proven tool for learning from errors and, when effectively implemented, can improve quality and safety. Crew resource management (CRM) employs just culture principles with a team-based safety system. The pillars of CRM include mandatory error reporting and structured training to proactively identify, learn from, and mitigate incidents. High-reliability organizations, such as commercial aviation, have achieved exemplary safety performance since adopting CRM strategies. Objective Our aim was to double the rate of staff error reporting from baseline rates utilizing CRM strategies during a six-month study period in a hospital-based radiation oncology (RO) department. Methods This quasi-experimental study involved a retrospective review of reported radiation oncology incidents between January 2015 and March 2016, which helped inform the development and implementation of a two-step custom CRM training and incident learning system (ILS) intervention in May 2016. A convenience sample of approximately 50 RO staff (Staff) performing over 100 external beam and daily brachytherapy treatments participated in weekly training for six months while continuing to report errors on a hospital-enterprise system. A discipline-specific incident learning system (ILS) customized for the department was added during the last three months of the study, enabling staff to identify, characterize, and report incidents and potential errors. Weekly process control charts used to trend incident reporting rates (total number of reported incidents in a given month /1000 fractions), and custom reports characterizing the potential severity as well as the location of incidents along the treatment path, were reviewed, analyzed, and addressed by an RO multidisciplinary project committee established for this study. Results A five-fold increase in the monthly reported number of incidents (n = 9.3) was observed during the six-month intervention period as compared to the 16-month pre-intervention period (n = 1.8). A significant increase (>3 sigma) was observed when the custom reporting system was added during the last three study months. Conclusion A discipline-specific electronic ILS enabling the characterization of individual RO incidents combined with routine CRM training is an effective method for increasing staff incident reporting and engagement, leading to a more systematic, team-based mitigation process. These combined strategies allowed for real-time reporting, analysis, and learning that can be used to en...

The Barriers and Enhancers to Trust in a Just Culture in Hospital Settings: A Systematic Review

“…17 Managers and leaders have a substantial impact on error communication, and their attitude, commitment, and openness are essential to foster trust in error reporting. 7,12,14,23 Because a good staff-manager relationship is beneficial to communication, 7 a surveillance-oriented approach to error reporting can generate distrust in error communication. If executives check up on staff, staff tend to cover up or hide mistakes.…”

“…In their study, Auer et al 12 concluded that the more hospital management supports patient safety, the more nurses trust hospital management, which is beneficial for safety-related communication. Swanson et al 23 also found that the commitment of leadership to a culture of safety also stimulates trust. For example, openness on the part of medical directors about near medical misses stimulates trust among staff.…”

“…For example, openness on the part of medical directors about near medical misses stimulates trust among staff. 23 Furthermore, medical management that does not adequately support physicians in taking responsibility for patient safety may erode trust in that management. 14 In addition, staff have more trust in managers if, in the case of errors, managers look at the whole system rather than blame one individual and provide a clear explanation about how medical errors will be handled.…”

“…Swanson et al 23 To double the rate of staff error reporting from baseline rates utilizing crew resource management strategies during a 6-month study period. A retrospective survey study.…”

Clinical incident reporting behaviors and associated factors among health professionals in Dessie comprehensive specialized hospital, Amhara Region, Ethiopia: a mixed method study

“…Training on clinical incident reporting significantly improves the health worker's skills in analyzing the factors of incidents with the prevention of future occurrence of medical errors. In addition, Training can improve systematic and structural strategies for recognizing, reporting, learning about, and characterizing incidents [21], and increasing the health care professional awareness on reporting medical errors can promote effectiveness to protect patients from incidents [22].…”