The use of categorized time-trend reporting of radiation oncology incidents: a proactive analytical approach to improving quality and safety over time.
OBJECTIVE
Radiotherapy is a common treatment for cancer patients. Although incidence of error is low, errors can be severe or affect significant numbers of patients. In addition, errors will often not manifest until long periods after treatment. This study describes the development of an incident reporting tool that allows categorical analysis and time trend reporting, covering first 3 years of use.


METHODS
A radiotherapy-specific incident analysis system was established. Staff members were encouraged to report actual errors and near-miss events detected at prescription, simulation, planning, or treatment phases of radiotherapy delivery. Trend reporting was reviewed monthly.


RESULTS
Reports were analyzed for the first 3 years of operation (May 2004-2007). A total of 688 reports was received during the study period. The actual error rate was 0.2% per treatment episode. During the study period, the actual error rates reduced significantly from 1% per year to 0.3% per year (p < 0.001), as did the total event report rates (p < 0.0001). There were 3.5 times as many near misses reported compared with actual errors.


CONCLUSIONS
This system has allowed real-time analysis of events within a radiation oncology department to a reduced error rate through focus on learning and prevention from the near-miss reports. Plans are underway to develop this reporting tool for Australia and New Zealand.
Arnold
Anthony
A
Illawarra Cancer Care Centre, Wollongong Hospital, Wollongong, New South Wales, Australia. anthony.arnold@sesiahs.health.nsw.gov.au
Delaney
Geoff P
GP
Cassapi
Lynette
L
Barton
Michael
M
D001315:Australia; D016208:Databases, Factual; D006801:Humans; D015994:Incidence; D019300:Medical Errors / Q000517:prevention & control* / Q000706:statistics & numerical data / Q000639:trends; D055656:Prescriptions / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care; D018787:Radiation Oncology / Q000706:statistics & numerical data* / Q000639:trends; D011878:Radiotherapy / Q000009:adverse effects* / Q000706:statistics & numerical data; D011880:Radiotherapy Planning, Computer-Assisted / Q000706:statistics & numerical data; D017751:Safety Management / Q000379:methods* / Q000706:statistics & numerical data / Q000639:trends; D013997:Time Factors