title: Incident learning in pursuit of high reliability: implementing a comprehensive, low-threshold reporting program in a large, multisite radiation oncology department.
abstract: BACKGROUND
  Incident learning programs have been recognized as cornerstones of safety and quality assurance in so-called high reliability organizations in industries such as aviation and nuclear power. High reliability organizations are distinguished by their drive to continuously identify and proactively address a broad spectrum of latent safety issues. Many radiation oncology institutions have reported on their experience in tracking and analyzing adverse events and near misses but few have incorporated the principles of high reliability into their programs. Most programs have focused on the reporting and retrospective analysis of a relatively small number of significant adverse events and near misses. To advance a large, multisite radiation oncology department toward high reliability, a comprehensive, cost-effective, electronic condition reporting program was launched to enable the identification of a broad spectrum of latent system failures, which would then be addressed through a continuous quality improvement process.
  
  
  METHODS
  A comprehensive program, including policies, work flows, and information system, was designed and implemented, with use of a low reporting threshold to focus on precursors to adverse events.
  
  
  RESULTS
  In a 46-month period from March 2011 through December 2014, a total of 8,504 conditions (average, 185 per month, 1 per patient treated, 3.9 per 100 fractions [individual treatments]) were reported. Some 77.9% of clinical staff members reported at least 1 condition. Ninety-eight percent of conditions were classified in the lowest two of four severity levels, providing the opportunity to address conditions before they contribute to adverse events.
  
  
  CONCLUSIONS
  Results after approximately four years show excellent employee engagement, a sustained rate of reporting, and a focus on low-level issues leading to proactive quality improvement interventions.
authors.affiliation: Department of Radiation Oncology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA.
authors.forename: Peter E
authors.initials: PE
authors.lastname: Gabriel
authors.forename: Edna
authors.initials: E
authors.lastname: Volz
authors.forename: Howard W
authors.initials: HW
authors.lastname: Bergendahl
authors.forename: Sean V
authors.initials: SV
authors.lastname: Burke
authors.forename: Timothy D
authors.initials: TD
authors.lastname: Solberg
authors.forename: Amit
authors.initials: A
authors.lastname: Maity
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hahn
mesh_terms: D003628:Database Management Systems; D006302:Health Services Research; D006748:Hospital Departments / Q000458:organization & administration*; D006801:Humans; D015279:Organizational Culture; D016134:Organizational Policy; D010414:Pennsylvania; D058996:Quality Improvement; D018787:Radiation Oncology / Q000458:organization & administration*; D015203:Reproducibility of Results; D012308:Risk Management / Q000379:methods*; D017751:Safety Management; D012984:Software; D057188:Workflow