Implementation and operation of incident learning across a newly-created health system

Journal of Applied Clinical Medical Physics
Leah SchubertArthur Liu

Abstract

The purpose of this work is to describe our experience launching an expanded incident learning system for patient safety and quality that takes into account aspects beyond therapeutic dose delivery, specifically imaging/simulation incidents, medical care incidents, and operational issues. Our ILS was designed for a newly created health system comprised of a midsized academic hospital and two smaller community hospitals. The main design goal was to create a highly sensitive system to capture as much information throughout the department as possible. Reports were classified according to incidents and near misses involving therapeutic radiation, imaging/simulation, and patient care (not involving radiation), unsafe conditions, operational issues, and accolades/suggestions. Reports were analyzed according to impact on various steps in the process of care. Actions made in response to reports were assessed and characterized by intervention reliability. A total of 1125 reports were submitted in the first 23 months. For all three departments, therapeutic radiation incidents and near misses consisted of less than one-third of all reports submitted. For the midsized academic department, operational issues and unsafe conditions comprised ...Continue Reading

References

Apr 12, 1990·Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences·J Reason
Jun 15, 2010·Radiotherapy and Oncology : Journal of the European Society for Therapeutic Radiology and Oncology·Jean-Pierre Bissonnette, Gaylene Medlam
Dec 26, 2012·International Journal of Radiation Oncology, Biology, Physics·Stephanie A TerezakisHiram Gay
Apr 9, 2013·International Journal of Radiation Oncology, Biology, Physics·John A KalapurakalBharat B Mittal
Mar 29, 2014·Practical Radiation Oncology·Brenda G ClarkPeter Dunscombe
Nov 22, 2014·Practical Radiation Oncology·Aaron S KusanoEric C Ford
Dec 3, 2014·International Journal of Radiation Oncology, Biology, Physics·Douglas A RahnTodd Pawlicki
Aug 2, 2015·Practical Radiation Oncology·Matthew J NyflotEric C Ford
Sep 13, 2015·Practical Radiation Oncology·David J HoopesEric C Ford
Nov 19, 2015·Practical Radiation Oncology·Leah SchubertChristine Fisher

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Citations

Nov 3, 2020·Reports of Practical Oncology and Radiotherapy : Journal of Greatpoland Cancer Center in Poznań and Polish Society of Radiation Oncology·Lucas Augusto RadicchiDário Henrique Alliprandini
May 26, 2020·Practical Radiation Oncology·Jean L WrightEric Ford

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