Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy : The Primary Experience in a New Established Program with Advanced Technology
Joint Authors
Zhang, Xile
Sun, Haitao
Lin, Lei
Yang, Ruijie
Gao, Yang
Liu, Lu
Wang, Junjie
Source
Issue
Vol. 2014, Issue 2014 (31 Dec. 2014), pp.1-7, 7 p.
Publisher
Hindawi Publishing Corporation
Publication Date
2014-07-22
Country of Publication
Egypt
No. of Pages
7
Main Subjects
Abstract EN
Objective.
To explore the implementation of incident learning for quality management of radiotherapy in a new established radiotherapy program.
Materials and Methods.
With reference to the consensus recommendations by American Association of Physicist in Medicine, an incident learning system was specifically established for reporting, investigating, and learning of individual incidents.
The incidents that occurred in external beam radiotherapy from February, 2012, to February, 2014, were reported.
Results.
A total of 28 near misses and 5 incidents were reported.
Among them, 5 originated in imaging for planning, 25 in planning, and 1 in plan transfer, commissioning, and delivery, respectively.
One near miss/incident was classified as wrong patient, 7 wrong sites, 6 wrong laterality, and 5 wrong dose.
Five reported incidents were all classified as grade 1/2 of dosimetric severity, 1 as grade 0, and the other 4 as grade 1 of medical severity.
For the causes/contributory factors, negligence, policy not followed, and inadequate training contributed to 19, 15, and 12 near misses/incidents, respectively.
The average incident rate per 100 patients treated was 0.4.
Conclusion.
Effective implementation of incident learning can reduce the occurrence of near misses/incidents and enhance the culture of safety.
American Psychological Association (APA)
Yang, Ruijie& Wang, Junjie& Zhang, Xile& Sun, Haitao& Gao, Yang& Liu, Lu…[et al.]. 2014. Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy : The Primary Experience in a New Established Program with Advanced Technology. BioMed Research International،Vol. 2014, no. 2014, pp.1-7.
https://search.emarefa.net/detail/BIM-468545
Modern Language Association (MLA)
Yang, Ruijie…[et al.]. Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy : The Primary Experience in a New Established Program with Advanced Technology. BioMed Research International No. 2014 (2014), pp.1-7.
https://search.emarefa.net/detail/BIM-468545
American Medical Association (AMA)
Yang, Ruijie& Wang, Junjie& Zhang, Xile& Sun, Haitao& Gao, Yang& Liu, Lu…[et al.]. Implementation of Incident Learning in the Safety and Quality Management of Radiotherapy : The Primary Experience in a New Established Program with Advanced Technology. BioMed Research International. 2014. Vol. 2014, no. 2014, pp.1-7.
https://search.emarefa.net/detail/BIM-468545
Data Type
Journal Articles
Language
English
Notes
Includes bibliographical references
Record ID
BIM-468545