Patient Safety and Process Improvements in Radiation Therapy through 10 Years of Incident Reporting and Learning

Abstract

It has been advocated by health care leaders that incident learning systems are important for error prevention and process improvement in the radiation therapy (RT). We have designed a web-based system for reporting any individual events in RT and clinical implemented in 2007. The goal of this study is to quantify the impact of a large-volume, department-wide incidental learning system on patient safety and process improvements. Materials/Methods: Over a ten-year period, our clinic practice was encouraged to voluntary report any occurrence that could have or had resulted in a deviation including events with low risk deviations and the events which have no impact on patients but which could provide a better process. The spectrum of reported events extended from minor workflow issues (e.g. scheduling or disruption of workflow, etc) to errors in treatment delivery. In addition to event reporting, the learning system also includes accolade reporting (e.g. reporting of someone doing something nice or helping to improve patient care) to build a strong organization culture. A multidisciplinary committee was assigned to review the reported events biweekly and to facilitate proactive measures (e.g. develop new process or procedures) to improve the patient safety and process or workflow. The ten-year data were retrospectively analyzed and mapped to RT process to determine in which workflow step(s) events are likely to occur and/or first to be discovered. Results: Between 2008 and 2017, a total of 13,786 events including 420 accolades were reported. 128 (<1%) events were reported as severe risks. The overall incident rate per 1000 patients has reduced over time. In most sub processes, the incident rates have significant reduced since 2012 after several interventions were introduced. For examples, the occurrence of incomplete or wrong MD orders has decreased from 104 to 0 from 2012 to 2017; the reported incidence on planning and plan preparation issues by dosimetrists reduced by 75% and the missing treatment approval by physicists reduced by 50%; the software and hardware related issues have been reduced by 70%. We have found that physicist chart review, therapist (both treatment and simulation) chart review, dosimetry planning, and physics weekly chart check are the four most important processes to identity the safety and process issues. Among the 13,876 events, 1,021 incidents were related to staff communication issues. Conclusion: Our data demonstrate that effective implementation and use of an incident learning system can successfully encourage reporting of incidents. Event reporting and accolades serve as a proactive means to improve safety, workflow and organization culture. We have also identified that communication issues among therapists, dosimetrists, physicists and physicians is one of the largest root causes for the incidents in a large RT department.