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.

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.

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

The development trend of the safety management system (sms) and the quality management system (qms), the formation of a unified corporate governance system in the “compliance management” format in the civil aviation

2020 ◽  
pp. 72-76
Author(s):  
A.A. Hasimov
Keyword(s):  
Quality Management ◽  
Management System ◽  
Safety Management ◽  
Quality Management System ◽  
Development Trend ◽  
Civil Aviation ◽  
Corporate Management ◽  
Governance System ◽  
Safety Management System ◽  
Effective Implementation

The article considers the role of integration processes of the quality management system in the field of civil aviation. The process of effective implementation of IMS in the corporate environment is taken into consideration and substantiated. The analysis of ICAO-9859 Document is carried out and the need for the implementation of an integrated corporate management system in organizations operating in civil aviation is substantiated. The advantages of using integrated systems are substantiated. General and specific principles of the Safety Management System (SMS) and Quality Management System (QMS) are highlighted. The created system for the effective implementation of the IMS is considered using a specific example of applying the requirements of the “Safety Management Manual”.

scholarly journals Public Roads as Places of Interspecies Conflict: A Study of Horse-Human Interactions on UK Roads and Impacts on Equine Exercise

Animals ◽  
2021 ◽  
Vol 11 (4) ◽  
pp. 1072
Author(s):  
Danica Pollard ◽  
Tamzin Furtado
Keyword(s):  
Near Miss ◽  
Online Questionnaire ◽  
Near Misses ◽  
Logistic Regression Models ◽  
Emotional Management ◽  
The Road ◽  
Human Interactions ◽  
Road Users ◽  
Conflict Risk ◽  
The Individual

Real or perceived traffic risk is a significant barrier to walking and cycling. To understand whether similar barriers influence equestrians, this study obtained exercise behaviours, road use and experiences of road-related incidents from UK equestrians (n = 6390) via an online questionnaire. Multivariable logistic regression models were used to identify factors associated with road use and experiencing a near-miss or injury-causing incident in the previous year. Content analysis identified themes around equestrians’ decisions not to use roads. Our results show that most equestrians (84%) use roads at least once weekly, and in the previous year, 67.7% had a near-miss and 6.1% an injury-causing incident. Road use differs regionally, with exercise type and off-road route availability. Road-using equestrians covered greater daily distances and were younger. However, younger equestrians were at higher risk of near-misses. Respondents’ decisions not to use roads were based on individualised risk assessments arising from: the road itself, perceptions of other road users, the individual horse and the handler’s own emotional management. Roads were perceived as extremely dangerous places with potentially high conflict risk. Injury-causing incidents were associated with increasing road-use anxiety or ceasing to use roads, the proximity of off-road routes, having a near-miss and type of road use. Targeted road-safety campaigns and improved off-road access would create safer equestrian spaces.

scholarly journals A Generalized Structural Equation Model Approach to Long Working Hours and Near-Misses among Healthcare Professionals in Japan

2021 ◽  
Vol 18 (13) ◽  
pp. 7154
Author(s):  
Tatsuhiko Anzai ◽  
Takashi Yamauchi ◽  
Masaki Ozawa ◽  
Kunihiko Takahashi
Keyword(s):  
Indirect Effects ◽  
Structural Equation ◽  
Healthcare Professionals ◽  
Sleep Problems ◽  
Working Hours ◽  
Near Miss ◽  
Long Working Hours ◽  
Near Misses ◽  
Related Stress ◽  
Job Related Stress

(1) Background: Near-miss incidents are the foundation of major injuries. They are warning signs that loss is imminent. Long working hours are a risk factor for near-misses along with sleep problems, job-related stress, and depressive symptoms. This study aimed to evaluate the indirect effects of long working hours via mediating variables on near-miss occurrences among Japanese healthcare professionals. (2) Methods: 1490 Japanese healthcare professionals’ reports from a web-based survey of workers in October 2018 were analyzed to evaluate total, direct, and indirect effects of long working hours on near-misses. We applied a generalized structural equation model with three mediating variables: sleep problems, job-related stress, and depressive symptoms. (3) Results: The total effect and direct effect of the categories of working hours longer than 41 h per week (h/w) for occurrence of near-misses were not significantly higher than that of 35–40 h/w. However, for indirect effects on occurrence of near-misses that first passed through job-related stress, there were higher reports for each category compared to 35–40 h/w, with odds ratios (OR) and 95% confidence intervals (95% CI) of OR = 1.12, 95% CI (1.07, 1.21) for 41–50 h/w; 1.25, (1.14, 1.41) for 51–60 h/w; and 1.31, (1.18, 1.51) for ≥ 61 h/w. (4) Conclusion: The results suggest that reducing working hours might improve job-related stress, which could reduce near-misses and prevent injuries.

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