title: Factors associated with event reporting in the pediatric radiation oncology population using an electronic incident reporting system.
abstract: OBJECTIVE
  Pediatric patients may receive complex treatment. In our department, an electronic incident reporting system (condition reporting system [CRS]) was developed and made available to all members.
  
  
  METHODS
  The CRS system is available on all departmental computers. Entered events are evaluated and graded by a supervisor as follows: "A"(dose deviation or patient harm), "B" (near miss), "C" (interruption in care process), or "D" (inconvenience). Data for pediatric patients for whom events were entered were reviewed retrospectively and compared to the entire treated pediatric population.
  
  
  RESULTS
  Over 2 years, 503 pediatric patients received radiation therapy (median age 10.1 years; range, 0.5-18.8 years), and 592 pediatric CRS events were entered (9.8% of 6020 total institutional CRS entries). These concerned 275 patients with an average of 2.1 entries each; 59% (348) were graded as severity D, 39% (230) as C, 2% (14) as B, and none as A. Events were most commonly related to treatment process (32%, n = 188), followed by planning/dosimetry (19%, n = 109), anesthesia (15%, n = 86), scheduling/transport (13%, n = 73), and physics (10%, n = 62). Delays associated with events were ≤1 hour for most cases (83%, n = 474). Patient and treatment factors associated with CRS entry included total duration of radiation therapy, primary brain tumor, receipt of proton therapy, and receipt of double-scattered proton therapy. No significant differences were found based on age, sex, race, treatment intent (curative vs palliative), type of photon treatment (conformal vs intensity modulated radiation therapy vs arc), use of total body irradiation, or use of pencil beam scanning proton therapy.
  
  
  CONCLUSIONS
  An incident reporting system is a widely used part of the safety culture at our institution, which treats one of the largest pediatric patient volumes in North America. Most pediatric CRS-reported events are of minor severity. Longer treatment course and use of new and complex technologies appear to increase the likelihood of a CRS event within the pediatric population, which supports the need for increased safety processes when new techniques are initiated.
authors.affiliation: Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address: hill@uphs.upenn.edu.
authors.forename: Christine E
authors.initials: CE
authors.lastname: Hill-Kayser
authors.affiliation: Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Peter
authors.initials: P
authors.lastname: Gabriel
authors.affiliation: Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Edna
authors.initials: E
authors.lastname: Volz
authors.affiliation: Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Lustig
authors.affiliation: Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Zelig
authors.initials: Z
authors.lastname: Tochner
authors.affiliation: Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas.
authors.forename: Stephen M
authors.initials: SM
authors.lastname: Hahn
authors.affiliation: Department of Radiation Oncology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Amit
authors.initials: A
authors.lastname: Maity
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D018787:Radiation Oncology / Q000379:methods*; D012308:Risk Management / Q000379:methods*