Lessons From a Prospective Incident Learning System: Focus on Physician-Specific “Errors/Near-Misses” and “Errors” That Reached the Patient

2014 ◽  
Vol 90 (1) ◽  
pp. S128
Author(s):  
B.S. Chera ◽  
K.M. Deschesne ◽  
P. Mosaly ◽  
G.S. Tracton ◽  
L. Stravers ◽  
...  
Keyword(s):  
Learning System ◽  
Near Misses ◽  
Incident Learning ◽  
System Focus

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.

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

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 Attending and Resident Physician Engagement of the Radiation Oncology Incident Learning System (RO-ILS)

2019 ◽  
Vol 105 (1) ◽  
pp. E609-E610
Author(s):  
P. Kundu ◽  
P.J. Beron ◽  
F.I. Chu ◽  
N. Agazaryan ◽  
M.L. Steinberg ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Resident Physician ◽  
Learning System ◽  
Physician Engagement ◽  
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

RO-ILS: Radiation Oncology Incident Learning System: A report from the first year of experience

2015 ◽  
Vol 5 (5) ◽  
pp. 312-318 ◽  
Author(s):  
David J. Hoopes ◽  
Adam P. Dicker ◽  
Nadine L. Eads ◽  
Gary A. Ezzell ◽  
Benedick A. Fraass ◽  
...  
Keyword(s):  
Radiation Oncology ◽  
Learning System ◽  
First Year ◽  
System A ◽  
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

Radiation Oncology Incident Learning System (RO-ILS): Increasing stakeholder participation for safety and quality improvement.

2019 ◽  
Vol 37 (27_suppl) ◽  
pp. 232-232
Author(s):  
Carl Nelson ◽  
Lori Ann Roy ◽  
H. James Wallace
Keyword(s):  
Process Improvement ◽  
Medical Center ◽  
Stakeholder Participation ◽  
Incident Reporting ◽  
Learning System ◽  
Near Miss ◽  
Radiation Quality ◽  
Near Misses ◽  
Staff Members ◽  
Physician Participation

232 Background: RO-ILS was launched in 2014 and is free, web-based and in more than 500 U.S. radiation facilities. After RO-ILS was implemented at University of Vermont Medical Center (UVMMC), reporting of radiation incidents decreased and participation by radiation staff was limited. To improve incident reporting and participation, RO-ILS was relaunched for all radiation staff members at UVMMC with emphasis on improved system access and education on RO-ILS programmatic goals. Methods: Prior to RO-ILS, safety/quality incidents at UVMMC were submitted by radiation therapists, dosimetrists and physics staff on paper forms and reviewed monthly by the Radiation Quality Committee. After implementation of RO-ILS in 2016, RO-ILS incidents were reviewed by the UVMMC RO-ILS administrators with no formalized staff feedback. Due to decreasing staff submissions, RO-ILS relaunched September 2018 with increased training, scheduled submission review to radiation staff and identification of department champions. Results: Between April 2014 and May 2019, 270 radiation incidents were reported. Prior to RO-ILS, a median 8 incidents were reported per quarter but decreased to 6 per quarter after RO-ILS. After RO-ILS relaunch, median reported incidents increased to 42 per quarter. Radiation “Near Miss” events pre RO-ILS, post RO-ILS and with RO-ILS relaunch were reduced from 78% to 34% to 9%, while “Operational/Process Improvement” submissions increased from 17% pre RO-ILS to 49% post RO-ILS to 81% after relaunch. After RO-ILS relaunch, staff participation expanded to physicians, nursing and administrative staff for the first time, and physician participation increased from 0 to 50%. Conclusions: Following implementation of RO-ILS at UVMMC, radiation incident reporting initially decreased and the proportion of “Near Miss” reports decreased. After relaunch of RO-ILS, there was substantial increase in incident reporting involving all staff. As RO-ILS evolves at UVMMC, there is continued decrease in near misses and greater emphasis on “Process Improvement”. Continued education, reporting and feedback from RO-ILS submissions is recommended to maintain this high staff participation level.

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