title: Can emergent treatments result in more severe errors?: An analysis of a large institutional near-miss incident reporting database.
abstract: OBJECTIVE
  Emergent radiation treatments may be subject to more errors because of the compressed time frame. Few data exist on the magnitude of this problem or how to guide safety improvement interventions. The purpose of this study is to examine patterns of near-miss events in emergent treatments using a large institutional incident reporting system.
  
  
  METHODS
  Events in the incident reporting database from February 2012 to October 2013 were reviewed prospectively by a multidisciplinary team to identify emergent treatments. Reports were scored for potential near-miss risk index (NMRI) on a 0 to 4 scale. Workflow steps of where events originated and were detected were analyzed. Events were categorized by use of the causal factor system from the Radiation Oncology Incident Learning System. Mann-Whitney U tests were used to compare mean NMRI score, and Fisher exact tests were performed to compare the proportion of high-risk events between emergent and nonemergent treatments and between emergent treatments on weekdays and weekends or holidays.
  
  
  RESULTS
  Over the study period, approximately 1600 patients were treated, 190 of them emergently. Seventy-one incident reports were submitted for 55 unique patients. Fewer events were reported for emergent treatments than for nonemergent treatments (0.37 events per new treatment vs 0.86; P < .01). Mean risk index for emergent reports was 1.90 versus 1.48 for nonemergent reports (P < .01). Rate of NMRI 4 was 10% for emergent treatments versus 4% for nonemergent treatments (P < .01). Emergent treatments started on a weekend or holiday had a higher proportion of critical near-miss events than emergent treatments started during the week (37% vs 7.9%, P = .034).
  
  
  CONCLUSIONS
  In this study, fewer near-miss incidents were reported per treatment course for emergent treatments. This may be attributable to reporting bias. More importantly, when emergent near misses occur, they are of greater severity.
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington. Electronic address: wegao@uw.edu.
authors.forename: Wendy
authors.initials: W
authors.lastname: Gao
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Nyflot
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Avrey
authors.initials: A
authors.lastname: Novak
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Sponseller
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Loucille
authors.initials: L
authors.lastname: Jordan
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Joshua
authors.initials: J
authors.lastname: Carlson
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Kane
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Jing
authors.initials: J
authors.lastname: Zeng
authors.affiliation: Department of Radiation Oncology, University of Washington, Seattle, Washington.
authors.forename: Eric C
authors.initials: EC
authors.lastname: Ford
mesh_terms: D005260:Female; D006268:Health Facilities; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D011446:Prospective Studies; D012308:Risk Management / Q000379:methods*