Real-time Management of Incident Learning Reports in a Radiation Oncology Department

Publication date: Available online 8 May 2018
Source:Practical Radiation Oncology
Author(s): Jean L Wright, Arti Parekh, Byung-Han Rhieu, Valentina Opris, Annette Souranis, Amanda Choflet, Akila N Viswanathan, Theodore DeWeese, Todd McNutt, Stephanie A Terezakis
PurposeThe optimal approach to managing incident learning system (ILS) reports remains unclear. Here we describe our experience with prospective coding of events reported to the ILS, with comparisons of risk scores based on event type and process map location.Methods and MaterialsReported events were coded by type, origin, and method of discovery. Events were given Risk Priority Number (RPN) and a Near-Miss Risk Index (NMRI) score. We compared workflow versus near-miss events with respect to origin and detection in the process map and by risk scores. Chi square test was used to compare differences between workflow and near-miss events and comparison of RPN scores was done by independent t-test.ResultsDuring 2016, 1351 events were reported. 1300 (96.2%) were workflow and 51 (3.8%) near-miss. Workflow events were more likely to both originate in pre-treatment (1041/1300 , 81.2%), compared to near-miss (31/51, 62.7%, p=0.005), and to be detected pre-treatment (997/1300, 76.7%) compared to near-miss (24/51, 47%, p<0.001). Average occurrence (scale 1-10) was 6.14 for workflow vs 3.33 for near-miss events respectively (p<0.001); average severity was 2.94 vs 7.35 (p<0.001); average detectability was 1.33 vs 4.67 (p<0.001). Mean overall RPN was 22.4 for workflow vs 108.4 for near-miss events (p=0.07) and mean NMRI was 1.16 vs 3.19. Events originating and detected in treatment delivery had the greatest mean overall RPN (38.2 and 32.1) and NMRI scores (1.62 and 1.6).ConclusionsOur experience demonstrates that workflow event reports are far more common than near-misses, and that near-misses are more likely to both originate and be discovered in later treatment phases. The frequency of workflow reports highlights the imperative for safety and operational teams to work collaboratively to maximize the benefit of ILS. We suggest a potential utility of the RPN system to guide mitigation strategies for future near-miss events.



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