Room: AAPM ePoster Library
Purpose: The purpose of this study is to assess how quality and safety programs (QSP) can utilize patient safety tools such as reporting, situation-background-assessment-recommendation (SBAR) and Kamishibai cards (K-cards) to create a safety culture in a large academic radiation oncology (RO) practice.
Methods: In 2015 and 2018, our single institution RO practice assessed safety culture through Agency for Healthcare Research and Quality (AHRQ) Culture of Safety survey. Effectiveness of our QSP efforts is monitored via a modification of serious safety event rate (SSER) which we call the significant event rate (SER). SER uses a rolling 12-month average of significant events per 10,000 fractions. Based on our ILS leveling, anything leveled “1” (state reportable) or “2” (dose variance >5% or =<20%, shows risk of serious harm to patient, etc.), is considered a significant event.
Results: The 2015 AHRQ survey serves as our baseline data. After implementation of a new ILS, training for leadership, and a restructured QSP, the 2018 survey showed improvement in all areas except teamwork across hospital units and hospital handoffs & transitions. The three most improved categories were frequency of events reported, communication openness, and feedback & communication about error. After our 2018 survey, the SBAR tool was used to communicate significant events and immediate risk mitigation to the entire practice quickly. In addition, in 2018, as part of our effort to reduce override fatigue for therapists, K-cards were utilized to improve compliance and understanding of best practices. Results of these efforts are reflected by our decreasing SER, which peaked in December 2018 at 0.64 and as of January 2020 is at 0.35.
Conclusion: Based on Culture of Safety surveys and SER, the tools utilized have been effective at growing the safety culture and reducing errors within a large academic RO practice.
Not Applicable / None Entered.
IM/TH- Formal Quality Management Tools: General (most aspects)