open access

Vol 23, No 3 (2018)
Original research articles
Published online: 2018-05-01
Submitted: 2017-09-22
Get Citation

Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Stuart Greenham, Stephen Manley, Kirsty Turnbull, Matthew Hoffmann, Amara Fonseca, Justin Westhuyzen, Andrew Last, Noel J. Aherne, Thomas P. Shakespeare
DOI: 10.1016/j.rpor.2018.04.002
·
Rep Pract Oncol Radiother 2018;23(3):220-227.

open access

Vol 23, No 3 (2018)
Original research articles
Published online: 2018-05-01
Submitted: 2017-09-22

Abstract

Aim

To develop and apply a clinical incident taxonomy for radiation therapy.

Background

Capturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability.

Methods and materials

A clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care. The taxonomy was applied to all clinical incidents occurring at three integrated cancer centres for the years 2011–2015. Incidents were managed locally, audited and feedback disseminated to all centres.

Results

Across the five years the total incident rate (per 100 courses) was 8.54; the radiotherapy-specific coded rate was 6.71. The rate of true adverse events (unintended treatment and potential patient harm) was 1.06. Adverse events, where no harm was identified, occurred at a rate of 2.76 per 100 courses. Despite workload increases, overall and actual rates both exhibited downward trends over the 5-year period. The taxonomy captured previously unidentified quality assurance failures; centre-specific issues that contributed to variations in incident trends were also identified.

Conclusions

The application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.

Abstract

Aim

To develop and apply a clinical incident taxonomy for radiation therapy.

Background

Capturing clinical incident information that focuses on near-miss events is critical for achieving higher levels of safety and reliability.

Methods and materials

A clinical incident taxonomy for radiation therapy was established; coding categories were prescription, consent, simulation, voluming, dosimetry, treatment, bolus, shielding, imaging, quality assurance and coordination of care. The taxonomy was applied to all clinical incidents occurring at three integrated cancer centres for the years 2011–2015. Incidents were managed locally, audited and feedback disseminated to all centres.

Results

Across the five years the total incident rate (per 100 courses) was 8.54; the radiotherapy-specific coded rate was 6.71. The rate of true adverse events (unintended treatment and potential patient harm) was 1.06. Adverse events, where no harm was identified, occurred at a rate of 2.76 per 100 courses. Despite workload increases, overall and actual rates both exhibited downward trends over the 5-year period. The taxonomy captured previously unidentified quality assurance failures; centre-specific issues that contributed to variations in incident trends were also identified.

Conclusions

The application of a taxonomy developed for radiation therapy enhances incident investigation and facilitates strategic interventions. The practice appears to be effective in our institution and contributes to the safety culture. The ratio of near miss to actual incidents could serve as a possible measure of incident reporting culture and could be incorporated into large scale incident reporting systems.

Get Citation

Keywords

Radiation therapy; Incident reporting; Quality improvement; Safety

About this article
Title

Application of an incident taxonomy for radiation therapy: Analysis of five years of data from three integrated cancer centres

Journal

Reports of Practical Oncology and Radiotherapy

Issue

Vol 23, No 3 (2018)

Pages

220-227

Published online

2018-05-01

DOI

10.1016/j.rpor.2018.04.002

Bibliographic record

Rep Pract Oncol Radiother 2018;23(3):220-227.

Keywords

Radiation therapy
Incident reporting
Quality improvement
Safety

Authors

Stuart Greenham
Stephen Manley
Kirsty Turnbull
Matthew Hoffmann
Amara Fonseca
Justin Westhuyzen
Andrew Last
Noel J. Aherne
Thomas P. Shakespeare

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