Source:Reports of Practical Oncology & Radiotherapy, Volume 23, Issue 3
Author(s): Stuart Greenham, Stephen Manley, Kirsty Turnbull, Matthew Hoffmann, Amara Fonseca, Justin Westhuyzen, Andrew Last, Noel J. Aherne, Thomas P. Shakespeare
AimTo develop and apply a clinical incident taxonomy for radiation therapy.BackgroundCapturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability.Methods and materialsA clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care. The taxonomy was applied to all clinical incidents occurring at three integrated cancer centres for the years 2011–2015. Incidents were managed locally, audited and feedback disseminated to all centres.ResultsAcross the five years the total incident rate (per 100 courses) was 8.54; the radiotherapy-specific coded rate was 6.71. The rate of true adverse events (unintended treatment and potential patient harm) was 1.06. Adverse events, where no harm was identified, occurred at a rate of 2.76 per 100 courses. Despite workload increases, overall and actual rates both exhibited downward trends over the 5-year period. The taxonomy captured previously unidentified quality assurance failures; centre-specific issues that contributed to variations in incident trends were also identified.ConclusionsThe application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.
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