title: Implementation of incident learning in the safety and quality management of radiotherapy: the primary experience in a new established program with advanced technology.
abstract: OBJECTIVE
  To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program.
  
  
  METHODS
  With reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically established for reporting, investigating, and learning of individual incidents. The incidents that occurred in external beam radiotherapy from February, 2012, to February, 2014, were reported.
  
  
  RESULTS
  A total of 28 near misses and 5 incidents were reported. Among them, 5 originated in imaging for planning, 25 in planning, and 1 in plan transfer, commissioning, and delivery, respectively. One near miss/incident was classified as wrong patient, 7 wrong sites, 6 wrong laterality, and 5 wrong dose. Five reported incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity. For the causes/contributory factors, negligence, policy not followed, and inadequate training contributed to 19, 15, and 12 near misses/incidents, respectively. The average incident rate per 100 patients treated was 0.4.
  
  
  CONCLUSIONS
  Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety.
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Ruijie
authors.initials: R
authors.lastname: Yang
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Junjie
authors.initials: J
authors.lastname: Wang
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Xile
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Haitao
authors.initials: H
authors.lastname: Sun
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Yang
authors.initials: Y
authors.lastname: Gao
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Lu
authors.initials: L
authors.lastname: Liu
authors.affiliation: Department of Radiation Oncology, Peking University Third Hospital, Beijing 100191, China.
authors.forename: Lei
authors.initials: L
authors.lastname: Lin
mesh_terms: D006801:Humans; D009369:Neoplasms / Q000532:radiotherapy*; D061766:Proton Therapy / Q000009:adverse effects / Q000379:methods*; D018787:Radiation Oncology / Q000193:education*; D011878:Radiotherapy / Q000009:adverse effects / Q000379:methods*; D012449:Safety