title: A real-time safety and quality reporting system: assessment of clinical data and staff participation.
abstract: OBJECTIVE
  To report on the use of an incident learning system in a radiation oncology clinic, along with a review of staff participation.
  
  
  METHODS
  On September 24, 2010, our department initiated an online real-time voluntary reporting system for safety issues, called the Radiation Oncology Quality Reporting System (ROQRS). We reviewed these reports from the program's inception through January 18, 2013 (2 years, 3 months, 25 days) to assess error reports (defined as both near-misses and incidents of inaccurate treatment).
  
  
  RESULTS
  During the study interval, there were 60,168 fractions of external beam radiation therapy and 955 brachytherapy procedures. There were 298 entries in the ROQRS system, among which 108 errors were reported. There were 31 patients with near-misses reported and 27 patients with incidents of inaccurate treatment reported. These incidents of inaccurate treatment occurred in 68 total treatment fractions (0.11% of treatments delivered during the study interval). None of these incidents of inaccurate treatment resulted in deviation from the prescription by 5% or more. A solution to the errors was documented in ROQRS in 65% of the cases. Errors occurred as repeated errors in 22% of the cases. A disproportionate number of the incidents of inaccurate treatment were due to improper patient setup at the linear accelerator (P<.001). Physician participation in ROQRS was nonexistent initially, but improved after an education program.
  
  
  CONCLUSIONS
  Incident learning systems are a useful and practical means of improving safety and quality in patient care.
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California.
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Rahn
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California.
authors.forename: Gwe-Ya
authors.initials: GY
authors.lastname: Kim
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California.
authors.forename: Arno J
authors.initials: AJ
authors.lastname: Mundt
authors.affiliation: Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California. Electronic address: tpawlicki@ucsd.edu.
authors.forename: Todd
authors.initials: T
authors.lastname: Pawlicki
mesh_terms: D001918:Brachytherapy / Q000295:instrumentation; D006801:Humans; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008503:Medical Staff / Q000193:education / Q000706:statistics & numerical data; D011785:Quality Assurance, Health Care / Q000706:statistics & numerical data*; D058996:Quality Improvement; D018787:Radiation Oncology / Q000295:instrumentation / Q000592:standards / Q000706:statistics & numerical data*; D011878:Radiotherapy / Q000295:instrumentation; D061106:Radiotherapy Setup Errors / Q000706:statistics & numerical data*; D012308:Risk Management / Q000379:methods*; D012449:Safety / Q000592:standards / Q000706:statistics & numerical data*; D014584:User-Computer Interface