title: Targeting safety improvements through identification of incident origination and detection in a near-miss incident learning system.
abstract: Radiation treatment planning involves a complex workflow that has multiple potential points of vulnerability. This study utilizes an incident reporting system to identify the origination and detection points of near-miss errors, in order to guide their departmental safety improvement efforts. Previous studies have examined where errors arise, but not where they are detected or applied a near-miss risk index (NMRI) to gauge severity.
  
  
  
  From 3/2012 to 3/2014, 1897 incidents were analyzed from a departmental incident learning system. All incidents were prospectively reviewed weekly by a multidisciplinary team and assigned a NMRI score ranging from 0 to 4 reflecting potential harm to the patient (no potential harm to potential critical harm). Incidents were classified by point of incident origination and detection based on a 103-step workflow. The individual steps were divided among nine broad workflow categories (patient assessment, imaging for radiation therapy (RT) planning, treatment planning, pretreatment plan review, treatment delivery, on-treatment quality management, post-treatment completion, equipment/software quality management, and other). The average NMRI scores of incidents originating or detected within each broad workflow area were calculated. Additionally, out of 103 individual process steps, 35 were classified as safety barriers, the process steps whose primary function is to catch errors. The safety barriers which most frequently detected incidents were identified and analyzed. Finally, the distance between event origination and detection was explored by grouping events by the number of broad workflow area events passed through before detection, and average NMRI scores were compared.
  
  
  
  Near-miss incidents most commonly originated within treatment planning (33%). However, the incidents with the highest average NMRI scores originated during imaging for RT planning (NMRI = 2.0, average NMRI of all events = 1.5), specifically during the documentation of patient positioning and localization of the patient. Incidents were most frequently detected during treatment delivery (30%), and incidents identified at this point also had higher severity scores than other workflow areas (NMRI = 1.6). Incidents identified during on-treatment quality management were also more severe (NMRI = 1.7), and the specific process steps of reviewing portal and CBCT images tended to catch highest-severity incidents. On average, safety barriers caught 46% of all incidents, most frequently at physics chart review, therapist's chart check, and the review of portal images; however, most of the incidents that pass through a particular safety barrier are not designed to be capable of being captured at that barrier.
  
  
  
  Incident learning systems can be used to assess the most common points of error origination and detection in radiation oncology. This can help tailor safety improvement efforts and target the highest impact portions of the workflow. The most severe near-miss events tend to originate during simulation, with the most severe near-miss events detected at the time of patient treatment. Safety barriers can be improved to allow earlier detection of near-miss events.
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Avrey
authors.initials: A
authors.lastname: Novak
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Nyflot
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Ralph P
authors.initials: RP
authors.lastname: Ermoian
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Loucille E
authors.initials: LE
authors.lastname: Jordan
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Patricia A
authors.initials: PA
authors.lastname: Sponseller
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Gabrielle M
authors.initials: GM
authors.lastname: Kane
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Eric C
authors.initials: EC
authors.lastname: Ford
authors.affiliation: Department of Radiation Oncology, University of Washington Medical Center, 1959 NE Pacific Street, Campus Box 356043, Seattle, Washington 98195.
authors.forename: Jing
authors.initials: J
authors.lastname: Zeng
mesh_terms: D006801:Humans; D000067491:Near Miss, Healthcare; D018787:Radiation Oncology / Q000295:instrumentation / Q000379:methods*; D011878:Radiotherapy / Q000009:adverse effects; D012308:Risk Management / Q000379:methods* / Q000706:statistics & numerical data; D012449:Safety