Vol 25, No 6 (2020)
Original research articles
Published online: 2020-11-01

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Critical success factors for implementation of an incident learning system in radiation oncology department

Lucas Augusto Radicchi1, José Carlos Toledo2, Dário Henrique Alliprandini3
DOI: 10.1016/j.rpor.2020.09.014
Rep Pract Oncol Radiother 2020;25(6):994-1000.



The aim of this study was to analyze critical success factors (CSFs) for implementation of an incident learning system (ILS) in a radiation oncology department (ROD) and evaluate the perception of the staff members along this process.


Implementing an ILS is a way to leverage learning from incidents and is a tool for improving patient safety, consisting of a cycle of reporting and analyzing events as well as taking preventive actions. ILS implementation is challenging, requiring specific resources and cultural changes.

Materials and methods

An ILS was designed and implemented based on the CSF identified in the literature review. Before starting the ILS implementation, a structured survey was applied to assess dimensions of patient safety culture. After the period of implementation (7 months), the survey was applied again and compared with the initial assessment, and interviews were performed with staff members to evaluate the overall satisfaction with ILS and CSFs.


Statistically significant improvements were observed in 5 dimensions (12 totals) of the safety culture survey, considering time points before and after the ILS implementation. According to interviewees, “Facilitating committee”, “Efficient data collection”, “Focus on improvement”, “Just culture” and “Feedback to users” were the most relevant CSFs.


The ILS designed and implemented at ROD was perceived as an important tool to support quality and safety initiatives, promoting the improvement in safety culture. The ILS implementation critical success factors were identified and have shown good agreement between the results of the literature and the users' practical perception.

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Reports of Practical Oncology and Radiotherapy