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Single-Institutional Experience in the Use of Unsafe Condition and Non-Safety Related Incident Reporting to Improve Radiotherapy Process of Care

J Lamb*, K Rose , W Chin , M Tesfaye , J Melkonian , A Raldow , P Beron , M Cao , P Lovelock , S McCloskey , M Steinberg , N Agazaryan , UCLA School of Medicine, Los Angeles, CA


(Tuesday, 7/31/2018) 9:30 AM - 10:00 AM

Room: Exhibit Hall | Forum 7

Purpose: Our institution uses the Radiation Oncology Incident Learning System (RO-ILS) to collect a high volume of reports of unsafe conditions and process improvement suggestions. Individually these event types present very low risk to patient safety, but collectively they may reveal significant patient experience and safety culture implications. The purpose of this abstract is to share our institution’s process for learning from these very low-risk high volume events, describe aggregate event features, and report key process improvements undertaken in response.

Methods: Events reported in the six month period starting June 1st, 2017 were analyzed. Events were categorized into thematic clusters during weekly institutional event review committee meetings, and retrospectively categorized according to the functional role of the reporting individual and the functional area in which the event originated. The suitability of the incident learning system for unsafe conditions and process improvement suggestions was evaluated and potential improvements identified.

Results: There were 93 total events reported in the analyzed time period, of which 76 were deemed very low risk. 63% of such events were reported by radiation therapy technologists, 15% by physicists or dosimetrists, 8% by front desk staff, and 9% by physicians. The four most common thematic clusters related to documentation inconsistencies and time pressure in the treatment plan approval process (48%), communication across functional areas (9%), patient interactions in the brachytherapy service (7%), and coordination of physician and patient schedules (4%). Analysis of the plan approval process cluster resulted in changes in the radiation therapist and physicists pre-treatment quality assurance processes and the plan approval and plan documentation processes. Following this intervention, the number of submitted events in the plan approval cluster decreased.

Conclusion: Based on this experience we believe that this use of the incident reporting system leads to measurable improvements in the process of care.


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