Improving Patient Safety Through Identification of Origination Points of Serious Errors in a Near-Miss Incident Learning System

2014 ◽  
Vol 90 (1) ◽  
pp. S130 ◽  
Author(s):  
A. Novak ◽  
M. Nyflot ◽  
P. Sponseller ◽  
J. Howard ◽  
W. Logan ◽  
...  
Keyword(s):  
Patient Safety ◽  
Learning System ◽  
Near Miss ◽  
Incident Learning

Durable Improvement in Patient Safety Culture Over 5 Years With Use of High-volume Incident Learning System

2019 ◽  
Vol 9 (4) ◽  
pp. e407-e416 ◽  
Author(s):  
Pehr E. Hartvigson ◽  
Aaron S. Kusano ◽  
Matthew J. Nyflot ◽  
Loucille Jordan ◽  
Tru-Khang Dinh ◽  
...  
Keyword(s):  
Patient Safety ◽  
Safety Culture ◽  
High Volume ◽  
Patient Safety Culture ◽  
Learning System ◽  
Incident Learning

scholarly journals OC-0081: Patient Safety Is Improved With An Extensive Incident Learning System—9 Years Of Clinical Evidence

2017 ◽  
Vol 123 ◽  
pp. S41-S42
Author(s):  
C. Deufel ◽  
L. McLemore ◽  
L. Fong de los Santos ◽  
K. Classic ◽  
S. Park ◽  
...  
Keyword(s):  
Patient Safety ◽  
Clinical Evidence ◽  
Learning System ◽  
Incident Learning

Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system

2016 ◽  
Vol 43 (5) ◽  
pp. 2053-2062 ◽  
Author(s):  
Avrey Novak ◽  
Matthew J. Nyflot ◽  
Ralph P. Ermoian ◽  
Loucille E. Jordan ◽  
Patricia A. Sponseller ◽  
...  
Keyword(s):  
Learning System ◽  
Near Miss ◽  
Incident Learning

scholarly journals Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy: The Primary Experience in a New Established Program with Advanced Technology

2014 ◽  
Vol 2014 ◽  
pp. 1-7 ◽  
Author(s):  
Ruijie Yang ◽  
Junjie Wang ◽  
Xile Zhang ◽  
Haitao Sun ◽  
Yang Gao ◽  
...  
Keyword(s):  
Quality Management ◽  
External Beam Radiotherapy ◽  
Learning System ◽  
Near Miss ◽  
Advanced Technology ◽  
Near Misses ◽  
Effective Implementation ◽  
Wrong Dose ◽  
Incident Rate ◽  
Incident Learning

Objective. To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program.Materials and Methods. With reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically established for reporting, investigating, and learning of individual incidents. The incidents that occurred in external beam radiotherapy from February, 2012, to February, 2014, were reported.Results. A total of 28 near misses and 5 incidents were reported. Among them, 5 originated in imaging for planning, 25 in planning, and 1 in plan transfer, commissioning, and delivery, respectively. One near miss/incident was classified as wrong patient, 7 wrong sites, 6 wrong laterality, and 5 wrong dose. Five reported incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, and inadequate training contributed to 19, 15, and 12 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4.Conclusion. Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety.

Patient Safety Across Disciplines: Radiation Oncology Incident Learning System

2015 ◽  
Vol 11 (3) ◽  
pp. 202-203 ◽  
Author(s):  
Suzanne B. Evans
Keyword(s):  
Patient Safety ◽  
Radiation Oncology ◽  
Reporting System ◽  
Learning System ◽  
Error Reporting ◽  
Error Reporting System ◽  
Corrective Actions ◽  
Incident Learning

The Radiation Oncology Incident Learning System is a national error reporting system that is voluntary and confidential. Participants collect and analyze their data, then institute corrective actions so that true incident learning takes place.

RO-ILS: Radiation Oncology Incident Learning System data trends 2014-2015.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 59-59
Author(s):  
David J. Hoopes ◽  
Eric C. Ford ◽  
Nadine L. Eads ◽  
Ksenija Kapetanovic ◽  
Cindy Tomlinson
Keyword(s):  
Patient Safety ◽  
Radiation Oncology ◽  
Quality Care ◽  
National Level ◽  
Safety Data ◽  
Learning System ◽  
Advisory Council ◽  
National Database ◽  
Junior Staff ◽  
Incident Learning

59 Background: Incident learning is one of the most effective ways to improve quality care. To facilitate patient safety improvement at a national level, American Society for Radiation Oncology (ASTRO) and American Association of Physicists in Medicine (AAPM) launched RO-ILS: Radiation Oncology Incident Learning System in June 2014. RO-ILS mission is to facilitate safer and higher quality care through a shared learning environment that is secure and non-punitive. Methods: To ensure the security and protection of data, ASTRO contracted with Clarity PSO, a federally-certified patient safety organization that operates under the auspices of the Patient Safety and Quality Improvement Act of 2005. Radiation oncology practices sign a no-fee contract with Clarity PSO to participate in RO-ILS and then enter safety data into a customized web-based portal. Submitted data are analyzed and interpreted by the Radiation Oncology Healthcare Advisory Council (RO-HAC), a multi-professional team. Practices receive aggregate quarterly reports and institutional reports when substantial data are submitted. Results: During the first year, 61 US practices (123) facilities signed contracts. 42 practices entered 1259 events and 619 of these events (49%) were submitted to the national database. Types of events included: 242 (39%) incidents that reached the patient with or without harm; 206 (33%) near-misses; and 171 (28%) unsafe conditions. RO-HAC identified risk-prone processes including ineffective communication, compressed timelines to start treatment, changes to treatment during the course of therapy and junior practitioners’ errors not remedied by experienced staff. Conclusions: Data suggests that quality assurance processes were effective in catching errors; however, continued work needs to address the origin of these errors and suggest robust solutions. To facilitate improved communication, effective protocols and software enhancements are recommended to alert staff to changes in patients’ management. Policies and procedures on patient hand-offs, emergency cases and oversight of junior staff will help error mitigation. While in its infancy, RO-ILS provides useful data and will serve to improve the quality and safety of radiotherapy.

Radiation therapist (RT) perceptions and practices related to safety culture (SC) and error reporting in radiation oncology.

2017 ◽  
Vol 35 (8_suppl) ◽  
pp. 42-42 ◽  
Author(s):  
David Hashemi ◽  
Kristina Demas Woodhouse ◽  
Brian Monzon ◽  
Seth A. Rosenthal ◽  
Neha Vapiwala
Keyword(s):  
Patient Safety ◽  
Radiation Oncology ◽  
Work Experience ◽  
Learning System ◽  
Error Reporting ◽  
Additional Patient ◽  
Safety Education ◽  
Multidisciplinary Communication ◽  
Treatment Facilities ◽  
Incident Learning

42 Background: The delivery of radiotherapy is complex and demands careful management, high vigilance, and precise coordination of clinical personnel. RTs are at the frontline and are often first to discover or report an error. However, few studies have examined RT patient safety practices. We conducted a national survey to explore the attitudes, training, and experiences of RTs related to safety in radiation oncology. Methods: In 2016, an electronic survey was sent in June and July to a random sample of 1,500 RTs (~10% of licensed RTs in the US). The survey assessed department SC, error reporting, knowledge, and practices. Questions were multiple choice or recorded on a 5-point Likert scale. Results were summarized using descriptive statistics and analyzed using multivariate logistic regression. Results: A total of 702 RTs from 48 states (47% response rate) completed the survey. Respondents represented a broad distribution across practice and geographic settings with varying levels of work experience (see table). Most RTs gave their department a “Patient Safety Grade” of Excellent (61%) or Very Good (32%), especially if they had an Incident Learning System (ILS) (OR: 2.0). Most departments (58%) had an ILS; however 59% of RTs had not reported an event in the previous year. When an error occurred but did not result in patient harm, 39% of RTs said they would report it and 37% said they would not. Bullying was reported among 17% of respondents; 40% reported that burnout, stress, and anxiety negatively impacted their ability to effectively treat patients. RTs reported errors were more likely to occur with longer work days (>8hrs) and poor multidisciplinary communication during handoffs and transitions. Most (62%) reported they could benefit from additional patient safety education and training, indicating significant interest in this topic. Conclusions: The majority of RTs reported excellent SC practices within their treatment facilities. Most facilities had systems in place to report errors. The obstacles identified, the results of this study may inform future educational efforts and safety initiatives directed towards RTs and should help increase awareness of patient SC in radiation oncology.

Reduction of radiation safety incident reporting following implementation of the radiation oncology incident learning system (RO-ILS).

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 236-236
Author(s):  
Carl Nelson ◽  
Lori Ann Roy ◽  
H. James Wallace
Keyword(s):  
Process Improvement ◽  
Radiation Oncology ◽  
Radiation Safety ◽  
Medical Physics ◽  
Incident Reporting ◽  
Learning System ◽  
Near Miss ◽  
Radiation Incident ◽  
Safety Incident ◽  
Incident Learning

236 Background: The Radiation Oncology Incident Learning System (RO-ILS) was initiated nationally June 2014 and is free, web-based, and currently used in more than 425 U.S. radiation facilities. RO-ILS was implemented at University of Vermont Medical Center (UVMMC) in October 2016 to facilitate safer, higher quality care. This implementation of RO-ILS was reviewed in order to determine whether the conversion to a new reporting system at UVMMC impacted radiation incident reporting at our institution. Methods: Radiation safety reporting at UVMMC included radiation incidents submitted by radiation therapists, dosimetrists and medical physics. Prior to RO-ILS, safety/quality incidents were submitted via a specified reporting form and submissions were reviewed monthly by the Radiation Oncology Quality Committee. After implementation of RO-ILS, radiation safety incidents were entered in RO-ILS and reviewed by the UVMMC RO-ILS administrator. Radiation incidents reported prior to October 2016 were entered into RO-ILS with the initial safety incident date. Results: Between April 2014 and May 2018, 136 radiation safety incidents were reported. There was a median of 7 incidents reported per quarter, decreasing from 8 to 6 per quarter after RO-ILS was implemented. Similarly, the average incidents per quarter was 8 and decreased from 8.9 to 6.7 per quarter after RO-ILS was implemented. Radiation incident types reported prior to RO-ILS were 78% “Near Miss” events but after RO-ILS decreased to 34%, while “Operational/Process Improvement” incidents increased from 17% pre RO-ILS to 49% post RO-ILS. The rate of radiation incidents reported per new patient starting radiation (the most frequent process associated with reported radiation incidents) was 0.59% and showed no significant trends or shifts before or after implementation of RO-ILS. Conclusions: Following implementation of RO-ILS at UVMMC, reported radiation incidents per quarter and the proportion of “Near Miss” events decreased, while the percentage of “Process Improvement” submissions increased. Further training and awareness of RO-ILS is planned with the goal of increasing staff participation and more robust reporting.

Psychological safety and near miss events in radiation oncology.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 231-231 ◽  
Author(s):  
Palak Kundu ◽  
Olivia Jung ◽  
Kathy Rose ◽  
Chonlawan Khaothiemsang ◽  
Nzhde Agazaryan ◽  
...  
Keyword(s):  
Risk Taking ◽  
Radiation Oncology ◽  
Psychological Safety ◽  
Learning Opportunities ◽  
Learning System ◽  
Near Miss ◽  
Radiation Process ◽  
Incident Learning ◽  
And Control ◽  
The Relationship

231 Background: Near miss events, defined as harm averted due to chance, are learning opportunities in radiation oncology. Psychological safety is a feature of a learning environment characterized by interpersonal risk taking. We examine the effects of near miss type and psychological safety on reporting near miss events to an incident learning system. We posit that submission likelihood will differ based on near miss types and psychological safety. Methods: We administered a survey assessing psychological safety to members of a radiation oncology department. We then presented six events for a patient with a pacemaker (PM), which requires cardiac clearance before radiation: process-based (harm averted by systematic PM check); good catch (harm averted by incidental PM check); “could” event (harm averted by chance PM absence); “almost” event (positive PM status, but no sequelae); hit (positive PM status, subsequent arrhythmia); and control (no PM, checked PM status, no sequelae). Subjects ranked each event on submission likelihood (1 = most likely, 7 = least likely), scored events based on submission likelihood by others (1 = least likely, 7 = most likely), and rated event success (1 = failure, 7 = success). ANOVA was used to assess differences in mean rank, submission likelihood, and success ratings. Regression was used to assess the relationship between psychological safety and submission likelihood. Results: The survey yielded 95 out of 127 responses (75%). Mean ranks (p < 0.0001), submission likelihood (p = .042), and success ratings (p < 0.001) differed by near miss type; psychological safety predicted likelihood of submitting the different near miss types (Table 1). 14 respondents (15%) would mind if an incident was submitted about them, while 43 respondents (45%) assume others would mind if an incident was reported related to the others (score > 4). Conclusions: Near miss events proximal to a negative outcome are more likely to be reported, though this effect may be mediated by psychological safety. [Table: see text]

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