MO-G-BRE-06: Metrics of Success: Measuring Participation and Attitudes Related to Near-Miss Incident Learning Systems

2014 ◽  
Vol 41 (6Part25) ◽  
pp. 433-433
Author(s):  
MJ Nyflot ◽  
AS Kusano ◽  
J Zeng ◽  
JC Carlson ◽  
A Novak ◽  
...  
Keyword(s):  
Learning Systems ◽  
Near Miss ◽  
Incident Learning

Interrater reliability of a near-miss risk index for incident learning systems in radiation oncology

2016 ◽  
Vol 6 (6) ◽  
pp. 429-435 ◽  
Author(s):  
Thomas Mullen ◽  
Matthew Nyflot ◽  
Jing Zeng ◽  
Loucille Jordan ◽  
Patricia A. Sponseller ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Interrater Reliability ◽  
Risk Index ◽  
Learning Systems ◽  
Near Miss ◽  
Incident Learning

Assessing the Interrater Reliability of a Near Miss Risk Index for Incident Learning Systems

2015 ◽  
Vol 93 (3) ◽  
pp. E501 ◽  
Author(s):  
T.D. Mullen ◽  
M. Nyflot ◽  
J. Zeng ◽  
L. Jordan ◽  
P.A. Sponseller ◽  
...  
Keyword(s):  
Interrater Reliability ◽  
Risk Index ◽  
Learning Systems ◽  
Near Miss ◽  
Incident Learning

Do Emergent Treatments Result in More Severe Errors? Analysis of a Large Institutional Near-Miss Incident Learning Database

2014 ◽  
Vol 90 (1) ◽  
pp. S129-S130
Author(s):  
W. Gao ◽  
M.J. Nyflot ◽  
M. Gensheimer ◽  
P. Sponseller ◽  
L. Jordan ◽  
...  
Keyword(s):  
Near Miss ◽  
Incident Learning ◽  
Errors Analysis

SU-E-T-310: Targeting Safety Improvements Through Analysis of Near-Miss Error Detection Points in An Incident Learning Database

2014 ◽  
Vol 41 (6Part16) ◽  
pp. 295-295
Author(s):  
A Novak ◽  
M Nyflot ◽  
P Sponseller ◽  
J Howard ◽  
W Logan ◽  
...  
Keyword(s):  
Error Detection ◽  
Near Miss ◽  
Incident Learning

TU-D-201-04: Veracity of Data Elements in Radiation Oncology Incident Learning Systems

2016 ◽  
Vol 43 (6Part34) ◽  
pp. 3743-3744 ◽  
Author(s):  
A Kapur ◽  
S Evans ◽  
D Brown ◽  
G Ezzell ◽  
D Hoopes ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Learning Systems ◽  
Data Elements ◽  
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.

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