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.

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]

Metrics of success: Measuring impact of a departmental near-miss incident learning system

2015 ◽  
Vol 5 (5) ◽  
pp. e409-e416 ◽  
Author(s):  
Matthew J. Nyflot ◽  
Jing Zeng ◽  
Aaron S. Kusano ◽  
Avrey Novak ◽  
Thomas D. Mullen ◽  
...  
Keyword(s):  
Learning System ◽  
Near Miss ◽  
Incident Learning

123 Supporting A Learning System in Paediatric Emergency Pathways; Using Organisational Comparisons, Serious Incidents and Near Miss Events To Improve The Diagnosis And Treatment Of Testicular Torsion

2021 ◽  
Vol 108 (Supplement_6) ◽  
Author(s):  
D Winters ◽  
A Mehmi ◽  
R Menzies-Wilson ◽  
S Folkard ◽  
K Ryan ◽  
...  
Keyword(s):  
Testicular Torsion ◽  
Statistical Significance ◽  
Lower Abdominal Pain ◽  
Learning System ◽  
Near Miss ◽  
Freedom Of Information ◽  
Atypical Presentation ◽  
Scrotal Pain ◽  
Paediatric Emergency ◽  
Qualitative Thematic Analysis

Abstract Introduction Scrotal pain is a common presentation to the emergency department requiring prompt investigation and management to identify testicular torsion. Using national data we aim to identify key suboptimal areas in the acute diagnosis and management of testicular torsion with a view to improving outcomes. Method A freedom of information request was made to all Trusts in England that manage testicular torsion. Serious Incidents (SI's) were analysed to see if those with Paediatric Emergency Departments fared better than those without. In addition, a qualitative thematic analysis of the NHS England Strategic Executive Information System database from 2007-2019 was undertaken, identifying common themes associated with orchidectomies and ‘near miss’ events in children. Results 304 serious incidents were returned with 62 Orchidectomies and 242 Near Miss Events. Misdiagnosis of symptomatic testicle was not significant when comparing ED to specialists (OR = 1.46, p = 0.3842). Atypical presentation resulting in orchidectomy was significant when comparing ED to specialists (OR = 6, p = 0.0355). Near miss events are due to a variety of factors. There was no statistical significance in incidents when comparing ED's caring for all ages with Paediatric EDs U = 807.5, z = -1.124, p = 0.261. Conclusions There's a need for education in ED about atypical presentation of testicular torsion and examination of scrotum in cases of lower abdominal pain. It's also vital that specialist teams are cognisant of the standard operating procedures relevant to scrotal pain. Finally, there should be a drive for annual audit in Urology and ED units with regards to testicular torsion as SI's may be under-reported.

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

scholarly journals Implementation of an On-line Incident Learning System in a Radiation Medicine Program

2019 ◽  
Vol 50 (2) ◽  
pp. S8
Author(s):  
Eric Dong ◽  
Agnes Cheung ◽  
Kevin Smith ◽  
Dana Zaremski ◽  
Erin Barnett ◽  
...  
Keyword(s):  
Learning System ◽  
Line Incident ◽  
On Line ◽  
Incident Learning ◽  
Radiation Medicine

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
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