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Quality Improvement: From Incident Learning to Affecting Change

E Ford1*, S Hedrick2*, Z Ouhib3*, S Evans4*, (1) University of Washington, Seattle, WA, (2) Provision Center for Proton Therapy, Knoxville, TN, (3) Lynn Regional Cancer Center, Delray Beach, FL, (4) Yale University, New Haven, CT


(Tuesday, 7/16/2019) 8:30 AM - 9:30 AM

Room: Stars at Night Ballroom 4

Incident learning is a key component of any robust quality management program. Though a vast majority of radiation oncology clinics employ a formal incident learning program it is often challenging to develop effective corrective actions to mitigate against incidents, near-misses and unsafe conditions. This session will explore the incident learning process and practical quality improvements approaches, drawing from the AAPM and ASTRO-sponsored system RO-ILS: Radiation Oncology Incident Learning System®. A participant will describe their experience with the RO-ILS system in the context of proton therapy; a representative of the ABS will describe a strategy for error mitigation that utilizes the professional community in a crowd-sourcing fashion; and a physician member of the RO-ILS analysis team will describe lessons learned from five-years of operations. Learning objectives for this session include understanding practical methods for corrective actions against risk and appreciating the value of incident learning at the national scale.

Learning objectives:
1. Develop effective corrective actions to mitigate potential incidents and near misses.
2. Apply systems thinking to quality initiatives such as error mitigation and compliance with accreditation standards.
3. Appreciate the value of national incident learning.



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