title: An evaluation of departmental radiation oncology incident reports: anticipating a national reporting system.
abstract: OBJECTIVE
  Systems to ensure patient safety are of critical importance. The electronic incident reporting systems (IRS) of 2 large academic radiation oncology departments were evaluated for events that may be suitable for submission to a national reporting system (NRS).
  
  
  METHODS
  All events recorded in the combined IRS were evaluated from 2007 through 2010. Incidents were graded for potential severity using the validated French Nuclear Safety Authority (ASN) 5-point scale. These incidents were categorized into 7 groups: (1) human error, (2) software error, (3) hardware error, (4) error in communication between 2 humans, (5) error at the human-software interface, (6) error at the software-hardware interface, and (7) error at the human-hardware interface.
  
  
  RESULTS
  Between the 2 systems, 4407 incidents were reported. Of these events, 1507 (34%) were considered to have the potential for clinical consequences. Of these 1507 events, 149 (10%) were rated as having a potential severity of ≥2. Of these 149 events, the committee determined that 79 (53%) of these events would be submittable to a NRS of which the majority was related to human error or to the human-software interface.
  
  
  CONCLUSIONS
  A significant number of incidents were identified in this analysis. The majority of events in this study were related to human error and to the human-software interface, further supporting the need for a NRS to facilitate field-wide learning and system improvement.
authors.affiliation: Department of Radiation Oncology and Molecular Radiation Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA. stereza1@jhmi.edu
authors.forename: Stephanie A
authors.initials: SA
authors.lastname: Terezakis
authors.forename: Kendra M
authors.initials: KM
authors.lastname: Harris
authors.forename: Eric
authors.initials: E
authors.lastname: Ford
authors.forename: Jeff
authors.initials: J
authors.lastname: Michalski
authors.forename: Theodore
authors.initials: T
authors.lastname: DeWeese
authors.forename: Lakshmi
authors.initials: L
authors.lastname: Santanam
authors.forename: Sasa
authors.initials: S
authors.lastname: Mutic
authors.forename: Hiram
authors.initials: H
authors.lastname: Gay
mesh_terms: D003144:Communication Barriers; D016287:Computer Peripherals / Q000706:statistics & numerical data; D006751:Hospital Information Systems / Q000706:statistics & numerical data*; D006801:Humans; D019300:Medical Errors / Q000145:classification* / Q000706:statistics & numerical data; D061214:Patient Safety; D018787:Radiation Oncology / Q000706:statistics & numerical data*; D011873:Radiology Information Systems / Q000706:statistics & numerical data; D012308:Risk Management / Q000145:classification* / Q000706:statistics & numerical data; D012984:Software; D014584:User-Computer Interface