title: Patient safety improvements in radiation treatment through 5 years of incident learning.
abstract: OBJECTIVE
  To quantify the impact of a comprehensive incident learning system in terms of safety improvements.
  
  
  METHODS
  An incident learning system tailored for radiation treatment and based on published principles has been used consistently in our large academic cancer center for more than 5 years. In the adopted system, every incident, whether or not there is a resulting direct impact on a patient treatment, is recorded and investigated to determine basic causes. The scope of the program thus includes potential, or near miss, events which have no impact on patients but which provide valuable insights into program weaknesses and hence facilitate proactive measures to minimize risk.
  
  
  RESULTS
  Analysis of 2506 incident reports generated over a 5-year period demonstrate a substantial decline in actual, nonminor incidents; ie, those with a dose variation from that prescribed of greater than 5%. Only 49 incidents (1.95%) had an impact on patients. The actual incident rate at the point of treatment delivery, the most vulnerable point in our process, has also decreased. The system has provided rapid feedback to monitor several initiatives including implementation of new technology and several new treatment techniques. Using the evidence provided by these incident reports, strategies were developed by a multidisciplinary team to address system weaknesses. Interventions introduced include several human error reduction strategies including forcing functions and constraints to improve system resilience.
  
  
  CONCLUSIONS
  Our results demonstrate that effective use of an incident learning system will strongly encourage the reporting of incidents, whether or not they directly impact a patient, and serve as a proactive means of enhancing safety and quality. As a side benefit, addressing and overcoming the cultural barriers between the 3 professional groups involved in radiation treatment has resulted in an improvement in the safety culture in our center.
authors.affiliation: Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada. Electronic address: brclark@toh.on.ca.
authors.forename: Brenda G
authors.initials: BG
authors.lastname: Clark
authors.affiliation: Radiation Medicine Program, The Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Brown
authors.affiliation: Radiation Safety and Health Physics, The Ottawa Hospital, Ottawa, Ontario, Canada.
authors.forename: Jodi
authors.initials: J
authors.lastname: Ploquin
authors.affiliation: Department of Medical Physics, Tom Baker Cancer Centre, Calgary, Alberta, Canada.
authors.forename: Peter
authors.initials: P
authors.lastname: Dunscombe