title: The management of radiation treatment error through incident learning.
abstract: OBJECTIVE
  To assess efficacy of an incident learning system in the management of error in radiation treatment.
  
  
  METHODS
  We report an incident learning system implementation customized for radiation therapy where any "unwanted or unexpected change from normal system behaviour 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 near-miss (potential) and actual events. Incidents are categorized according to severity, type and origin.
  
  
  RESULTS
  Our analysis spans a period of 3 years with an average accrual of 11.6 incidents per week. We found a significant reduction in actual incidents of 28% and 47% in the second and third year when compared to the first year (p<0.001), which we attribute to the many interventions prompted by the analysis of incidents reported. We also saw a similar significant reduction in incidents generated at the treatment unit correlating with the introduction of direct treatment parameter transfer and electronic imaging (p<0.001).
  
  
  CONCLUSIONS
  Implementation of an incident learning system has helped us to establish a just environment where all staff members report deviations from normal system behaviour and thus generate evidence to initiate safety improvements.
authors.affiliation: Radiation Medicine Program, The Ottawa Hospital Cancer Centre, Ottawa, ON K1H 8L6, Canada. brclark@ottawahospital.on.ca
authors.forename: Brenda G
authors.initials: BG
authors.lastname: Clark
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Brown
authors.forename: Jodi L
authors.initials: JL
authors.lastname: Ploquin
authors.forename: Anneke L
authors.initials: AL
authors.lastname: Kind
authors.forename: Laval
authors.initials: L
authors.lastname: Grimard
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000706:statistics & numerical data*; D009369:Neoplasms / Q000532:radiotherapy; D011878:Radiotherapy / Q000009:adverse effects*; D012308:Risk Management / Q000458:organization & administration*