WE-G-BRA-03: Developing a Culture of Patient Safety Utilizing the National Radiation Oncology Incident Learning System (ROILS)

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.

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

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.7_suppl.59 ◽

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.

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

Journal of Clinical Oncology ◽

10.1200/jco.2017.35.8_suppl.42 ◽

2017 ◽

Vol 35 (8_suppl) ◽

pp. 42-42 ◽

Cited By ~ 1

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.

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