Document Detail


The use of categorized time-trend reporting of radiation oncology incidents: a proactive analytical approach to improving quality and safety over time.
MedLine Citation:
PMID:  20598456     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
PURPOSE: Radiotherapy is a common treatment for cancer patients. Although incidence of error is low, errors can be severe or affect significant numbers of patients. In addition, errors will often not manifest until long periods after treatment. This study describes the development of an incident reporting tool that allows categorical analysis and time trend reporting, covering first 3 years of use.
METHODS AND MATERIALS: A radiotherapy-specific incident analysis system was established. Staff members were encouraged to report actual errors and near-miss events detected at prescription, simulation, planning, or treatment phases of radiotherapy delivery. Trend reporting was reviewed monthly.
RESULTS: Reports were analyzed for the first 3 years of operation (May 2004-2007). A total of 688 reports was received during the study period. The actual error rate was 0.2% per treatment episode. During the study period, the actual error rates reduced significantly from 1% per year to 0.3% per year (p < 0.001), as did the total event report rates (p < 0.0001). There were 3.5 times as many near misses reported compared with actual errors.
CONCLUSIONS: This system has allowed real-time analysis of events within a radiation oncology department to a reduced error rate through focus on learning and prevention from the near-miss reports. Plans are underway to develop this reporting tool for Australia and New Zealand.
Authors:
Anthony Arnold; Geoff P Delaney; Lynette Cassapi; Michael Barton
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  International journal of radiation oncology, biology, physics     Volume:  78     ISSN:  1879-355X     ISO Abbreviation:  Int. J. Radiat. Oncol. Biol. Phys.     Publication Date:  2010 Dec 
Date Detail:
Created Date:  2010-11-24     Completed Date:  2010-12-17     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  7603616     Medline TA:  Int J Radiat Oncol Biol Phys     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1548-54     Citation Subset:  IM    
Copyright Information:
Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.
Affiliation:
Illawarra Cancer Care Centre, Wollongong Hospital, Wollongong, New South Wales, Australia. anthony.arnold@sesiahs.health.nsw.gov.au
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MeSH Terms
Descriptor/Qualifier:
Australia
Databases, Factual
Humans
Incidence
Medical Errors / prevention & control*,  statistics & numerical data,  trends
Prescriptions / statistics & numerical data
Quality Assurance, Health Care
Radiation Oncology / statistics & numerical data*,  trends
Radiotherapy / adverse effects*,  statistics & numerical data
Radiotherapy Planning, Computer-Assisted / statistics & numerical data
Safety Management / methods*,  statistics & numerical data,  trends
Time Factors

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine


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