Learning from incidents in radiation treatment

Abstract

We have implemented an incident learning system designed for a radiation treatment program where any unwanted or unexpected change from a normal system behavior that causes or has the potential to cause an adverse effect to persons or equipment is reported, investigated and learned from. This system thus captures potential or near-miss in addition to actual events. Incidents are categorized according to severity, type and origin. After investigation, basic cause is assigned by asking a series of "why" questions and remedial action determined. Our results two years after implementation show a steady accrual of 658 and 686 incidents per year during 2007 and 2008 respectively, indicating good compliance with reporting. The majority of incidents reported are minor, resulting in less than 5% dose error, or potential, not impacting patient treatment in any way. Our results show a substantial reduction in actual incidents of 27% in the second year as compared to the first year, which we attribute to the many interventions instituted over the last 2 years resulting from the analysis of incidents reported. We have found that the incident learning system has helped us to establish a just environment where all staff members are able to report all deviations from normal system behavior and thus generate evidence to initiate process improvements to help manage errors our radiation treatment program. © 2009 Springer-Verlag.